Scion Dental KanCare Provider Manual

Transcription

D
Scion Dental
KanCare Provider ManualAmerigroup
Manual Effective January 1, 2013
Revision Date July 3, 2013
Provider Manual
Introduction ........................................................................................................................................................................................................... 3
Scion Dental Provider Experience ............................................................................................................................................................ 4
Our Commitment to Service .................................................................................................................................................................... 4
Access to Flexible Participation Options .................................................................................................................................................. 4
Outreach Programs ............................................................................................................................................................................... 4
Technology Tools ................................................................................................................................................................................... 5
Feedback ............................................................................................................................................................................................. 6
Quick Reference Information .................................................................................................................................................................................. 7
Provider Web Portal Registration & Introduction .................................................................................................................................................... 11
Registration ....................................................................................................................................................................................... 11
Introduction....................................................................................................................................................................................... 12
Provider Enrollment and Contracting Portal ........................................................................................................................................................... 19
Statement of Member Rights and Responsibilities ................................................................................................................................................ 20
Statement of Provider Rights and Responsibilities ................................................................................................................................................ 21
Member Eligibility Verification Procedures and Services to Members ..................................................................................................................... 22
Member Identification Card ................................................................................................................................................................. 22
Scion Dental Eligibility Systems ............................................................................................................................................................ 23
Transportation Benefits for Certain Members ......................................................................................................................................... 24
Appointment Availability Standards ...................................................................................................................................................... 24
Scion Dental Provider Manual .............................................................................................................................................................. 24
Covered Benefits .................................................................................................................................................................................................. 25
Missed Appointments.......................................................................................................................................................................... 26
Payment for Noncovered Services ......................................................................................................................................................... 26
Electronic Attachments........................................................................................................................................................................ 26
Prior Authorization, Retrospective Review and Documentation Requirements ........................................................................................................ 30
Procedures Requiring Prior Authorization .............................................................................................................................................. 30
Retrospective Review .......................................................................................................................................................................... 30
Orthodontic Models ............................................................................................................................................................................ 31
Claim Submission Procedures .............................................................................................................................................................................. 32
Electronic Claim Submission Utilizing Scion Dental’s Website ................................................................................................................. 32
Electronic Claim Submission via Clearinghouse ..................................................................................................................................... 32
HIPAA Compliant 837D File ................................................................................................................................................................. 32
Paper Claim Submission-Authorizations ................................................................................................................................................ 32
Facilities with Encounter Payments ....................................................................................................................................................... 35
Claims Adjudication and Payment ........................................................................................................................................................ 38
SCION DENTAL of KANSAS, LLC  CONFIDENTIAL | Provider Manual
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Coordination of Benefits (COB) ............................................................................................................................................................. 36
Filing Limits ...................................................................................................................................................................................... 368
Receipt and Audit of Claims ................................................................................................................................................................. 36
Inquiries, Grievances and Appeals ........................................................................................................................................................................ 37
Health Insurance Portability and Accountability Act (HIPAA) .................................................................................................................................. 42
Utilization Management Program ......................................................................................................................................................................... 43
Introduction ....................................................................................................................................................................................... 43
Community Practice Patterns ............................................................................................................................................................... 43
Evaluation .......................................................................................................................................................................................... 43
Results .............................................................................................................................................................................................. 43
Fraud and Abuse ................................................................................................................................................................................. 44
Deficit Reduction Act of 2005: The False Claims Act .............................................................................................................................. 44
Credentialing ....................................................................................................................................................................................................... 45
Important Notice for Submitting Paper Authorizations and Claims ......................................................................................................................... 46
Health Guidelines — Ages 0–18 Years................................................................................................................................................................... 50
Kansas Clinical Criteria for Prior Authorization of Treatment and Emergency Treatment .......................................................................................... 52
Authorization Requirements and Benefit Plan Details ............................................................................................................................................ 57
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Introduction
Welcome to the Scion Dental provider network! We are pleased you have joined our provider network, which is composed of the
best providers in the state. Scion Dental is a national leader in the administration of government dental benefits. We have
partnered with Amerigroup Kansas, Inc. to administer the dental benefit for their members in the KanCare managed care
program.
At the direction of Amerigroup, Scion Dental retains the right to add to, delete from and otherwise modify this provider manual.
Scion Dental will notify network providers 30 days prior to the effective date of changes to this manual. Contracted providers
must acknowledge this provider manual and any other written materials provided by Amerigroup or Scion Dental as proprietary
and confidential.
Dr. Fred Tye, Chief Dental Director
Dr. Tye serves as our chief dental director and oversees
all of Scion Dental’s clinical, utilization review and
utilization management activities. He also gives
guidance to our clinical review department to ensure
accuracy and consistency in the review process.
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Scion Dental Provider Experience
Committed dentists are critical to the success of every government-sponsored dental program. At Scion Dental, we have
structured our provider networks to give dentists the flexibility they need to participate in dental programs on their own terms.
Scion Dental considers itself an ally of dental associations while maintaining flexibility within the changing political climate
surrounding government-sponsored dental programs. We recognize the significant link between good dental care and overall
patient health, and advocate increasing provider funding while improving member education and outreach. Scion Dental
partners with dental providers to deliver high-quality care and services to all members of government-sponsored dental
programs.
Our Commitment to Service
Scion Dental has established the following core concepts in its approach to a positive provider experience:
Access: Access to flexible participation options in provider networks
Outreach: Outreach programs to lower provider participation costs
Technology: Technology tools to increase efficiency and lower administrative costs
Feedback: Feedback to measure provider and member satisfaction
Access to Flexible Participation Options
Scion Dental invites all licensed dentists, regardless of their past commitment
to government-sponsored dental programs, to participate in its provider
network. Providers can choose their own level of participation for each of their
practice locations. For example, providers can choose to:

Be listed in a directory and accept appointments for all new patients

Be excluded from the directory and accept appointments for only new
patients directed to their office from Scion Dental

Treat only emergencies or special needs cases on an individual basis

Access Web-based applications and credentialing
To make it easy to apply and be accepted into the program, Scion Dental uses
website links and electronic documents to streamline the provider/clinic
contracting and credentialing process.
Once providers participate in the Scion Dental network at any level, Web-based technology tools and innovative programs are
employed to drive down provider participation costs.
Outreach Programs
Lowering costs and ensuring a positive experience are the focus points for Scion Dental’s provider outreach programs.
Provider Bill of Rights
To be treated with respect.
To be paid accurately.
To be paid on time.
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Consistent, transparent authorization determination logic
Scion Dental’s trained paraprofessionals and dental consultants use clinical algorithms to ensure a consistent
approach for determining authorizations. These algorithms are available at the Provider Services website so dentists
can follow the decision matrix and understand the logic behind authorization decisions. In addition, Scion Dental
fosters a sense of partnership by encouraging providers to offer feedback about the algorithms. A consistent,
well-understood approach to authorization determinations promotes clarity and transparency for providers, which in
turn reduces provider administrative costs.
Technology Tools
Scion Dental takes advantage of technology to increase speed and efficiency while keeping program administration and
provider participation costs as low as possible.
Paperless insurance company
The paperless insurance company concept is a central component of Scion Dental’s attempt to eliminate paper
transactions. Replacing paper with electronic transactions lowers costs for providers and rewards them with
preferential status whenever possible. Providers can:

Submit claims and authorizations electronically, in any format convenient for the provider office

Receive remittances and payments

Verify member eligibility

Check claim and authorization status

View the results of member satisfaction surveys

Receive ongoing communication
Provider Web Portal
Scion Dental’s Provider Web Portal allows participating providers direct access to the Enterprise System benefits
administration software. Taking advantage of the online services offered through the Provider Web Portal lowers
program administration and participation costs.
Online access requires only an Internet browser, a valid user ID and a password. From an Internet browser, providers
and authorized office staff can log in for secured access to the system anytime from anywhere to handle a variety of
day-to-day tasks, including:

Verifying member eligibility

Checking patient treatment history for specific services

Submitting claims for services rendered by simply entering procedure codes, tooth numbers, etc.

Submitting authorization requests, using interactive clinical algorithms when appropriate

Sending electronic attachments, such as digital X-rays, Explanations of Benefits (EOBs) and treatment plans

Checking the status of submitted claims and authorizations

Accessing and reviewing remittance information

Downloading and printing provider manuals, clinical criteria, provider newsletters and fee schedules

Setting up office appointment schedules, which can automatically verify eligibility and prepopulate claim forms for
online submission
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
Reviewing provider clinical profiling data relative to peers

Uploading and downloading documents using a secure encryption protocol

Participating in provider surveys to rate satisfaction with Scion Dental
Feedback
At Scion Dental, feedback from members and providers is encouraged, logged and acted upon when appropriate. Scion Dental
conducts Web and telephone satisfaction surveys to gather valuable feedback for its Quality Improvement initiatives.
Additionally, Scion Dental invites feedback from providers regarding authorization determination algorithms to help foster a
sense of teamwork and cooperation.
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Quick Reference Information
Scion Dental provides access to a Web Portal containing the full complement of online provider resources. The Web Portal
features an online provider inquiry tool for real-time eligibility, claims and authorization status. Visit the Web Portal at
www.sciondental.com for helpful resources, including:

Standard forms

Scion provider manual

Referral directories

Provider newsletter

Claims status

Electronic remittance advice

Electronic funds transfer information
QUICK REFERENCE INFORMATION
Member Eligibility
National Provider Identifier (NPI)
Participating providers may access eligibility information through:

Logging in to Provider Web Portal via www.sciondental.com

Utilizing Scion Dental’s Interactive Voice Response (IVR) system
eligibility hotline at 1-855-812-9206

Contacting Scion Dental Provider Services at 1-855-812-9206
An NPI number is required to be submitted on all claims submitted for
payment. Please submit both your individual and billing NPI Numbers.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996
require the adoption of a standard unique provider identifier for health care
providers.
All participating providers must have an NPI number.
An NPI is a 10-digit, intelligence-free numeric identifier. Intelligence-free
means the numbers do not carry information concerning health care
providers, for instance, the states in which they practice or their specialties.
Providers can apply for an NPI by:

Completing the application online at https://nppes.cms.hhs.gov

Completing a paper copy by downloading it at https://nppes.cms.hhs.gov

Calling 1-800-465-3203 and requesting an application
 Estimated time to complete the NPI application is 20 minutes.
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Authorization Information
Prior authorization determinations must be made within 14 days from the
date Scion Dental receives this request, provided all information is
complete. See the section on prior authorization for more information.
Prior authorizations will be honored for 180 days from the date they are
determined as long as the member is enrolled with Amerigroup at the time
of service.
Authorization submissions can be received in the following formats:

Electronic authorizations via Scion Dental’s website at
www.sciondental.com

Electronic submission via a clearinghouse

HIPAA Compliant 837D file

Paper authorization via ADA 2006 Claim Form
Mailed authorizations should be sent to:
Scion Dental of Kansas – Authorizations
P.O. Box 1225
Milwaukee, WI 53201
Claims Information
The timely filing requirement for Amerigroup is 180 calendar days.
Claims submissions can be received in the following formats:

Electronic claims via Scion Dental’s website at www.sciondental.com

Electronic submission via clearinghouse

Electronic submission via KMAP Fiscal Agent (i.e., KanCare Front End
Billing)

HIPAA Compliant 837D file

Scion will only accept paper claims, through KanCare Front End Billing.
Submit claims to:
KanCare
P.O. Box 3571
Topeka, KS 66601-3571
All claims submitted through KanCare Front End Billing should include the
member’s Medicaid ID (sometimes known as a KMAP ID). Claims submitted
via Front End Billing with the Amerigroup ID will be rejected. All claims
should also include the Provider NPI Number.
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Retro-Review Claims
Inquiries and Grievances
Retro-Review claim submissions requires participating providers to
submit documentation associated with certain dental services rendered as
outlined in the benefit descriptions at the end of this manual.
Retro-Review claims can be received in the following formats: Electronic
submission via Scion Dental’s website at www.sciondental.com
Electronic submission via clearinghouse
Paper Retro-Review claims must be submitted through the KanCare Front Billing
process. Submit Retro-Review claims to:
KanCare
P.O. Box 3571
Topeka, KS 66601-3571
All Retro-Review requests submitted through KanCare Front End Billing
should include the member’s Medicaid ID (sometimes known as a
KMAP ID). Retro-Review claims submitted via Front End Billing with the
Amerigroup ID will be rejected. All Retro-Review claims should also
include the Provider NPI Number.
To make an inquiry or grievance, contact Scion Dental Provider Services toll
free at 1-855-812-9206.
To file a written grievance, send it to the following address:
Scion Dental of Kansas – Grievances
P.O. Box 1448
Milwaukee, WI 53201
Provider Appeals Information-Authorizations
Authorization Appeals must be filed within 33 days following the date the
denial letter was mailed.
To request reconsideration of a denied authorization, the Provider may call,
1-855-812-9206, or write:
Scion Dental of Kansas – Appeals
P.O. Box 1448
Milwaukee, WI 53201
Providers must exhaust their appeal rights with Scion Dental prior to
requesting a Fair Hearing. Fair Hearing requests must be submitted in
writing to the following address within 33 days of receipt of the letter with
Scion Dental’s final resolution:
Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612-1327
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Provider Appeals Information-Claims
Claim Payment Appeals must be filed within 90 days following the receipt of
the determination mailed.
To request a reconsideration of a claims denial, the Provider may call, 1855-812-9216 or write:
P.O. Box 1448
Milwaukee, WI 53201
Member Appeals Information
If a member would like to make a verbal appeal, contact Scion Dental
Member Services toll free at 1-855-866-2627.
Written appeals must be submitted to the following address:
P.O. Box 1448
Milwaukee, WI 53201
Fair Hearing requests must be submitted in writing to the following address:
1020 S. Kansas Ave.
Topeka, KS 66612-1327
Members that file verbal appeals must follow with a written, signed appeal
unless expedited resolution is requested.
Dental Services in a Hospital Setting
Providers need to treat members in a participating Amerigroup hospital. To
obtain the most recent listing of hospitals in your area, please visit
Amerigroup’s website at:
https://www.myamerigroup.com/english/medicaid/ks/pages/triage.aspx
You may also call Amerigroup Provider Services Phone: 1-800-454-3730
Additional Provider Resources
For information regarding additional provider resources, please contact:

Scion Dental Provider Services at 1-855-812-9206

Access the Scion Dental Provider Web Portal at www.sciondental.com

Email: [email protected]

Amerigroup Member Services at 1-855-866-2627
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Provider Web Portal Registration & Introduction
The Scion Dental Provider Web Portal services allow us to maintain our commitment to help providers keep office costs low,
access information efficiently, receive payments quicker and submit claims and authorizations electronically.
Registration
To register for our Provider Web Portal visit www.sciondental.com, click on the providers login tab, and follow the “Register Now”
link.
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There is no need to
download or purchase
software.
To access the Provider Web
Portal, enter a unique user
name and password.

Select “As a payee”
for the option to
view remittances.

Contact Provider
Services at
1-855-812-9206 to
obtain your Payee
ID number.
Introduction
Once registered, you are now ready to navigate through the Web Portal and use the available resources and features to help
streamline data entry.
Verify Member Eligibility

One-step member eligibility verification utilizing the Medicaid ID number as member indicator

Verify up to 250 members at one time
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Manage claims

Submit claims for services performed.

Review and print or save a list of claims submitted today for your records, before they are sent on for processing.

Check the status of previously submitted claims.

Enter additional information such as NEA# under the Notes tab.
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Authorizations

Submit authorizations before performing services to obtain approval.

Attach electronic files, including X-rays and review authorizations submitted today, before they are sent on for
processing.

Check the status of previously submitted authorizations.
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From an Authorization Summary, you can:

Run any applicable authorization guidelines.

Review a list of documentation required for each procedure code.

Attach electronic files to the authorization record.

Attach clearinghouse reference information to the authorization record.

Print a copy of the Authorization Summary for your records.
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Electronic Funds Transfer
The Scion Dental Provider Web Portal services allow us to give you quicker payments by Electronic Funds Transfers (EFTs).
The electronic payment offers a direct deposit into your account and allows you to obtain remits quicker on your online
account.
To obtain your online remittances, navigate to the My Documents page from the documents tab on the toolbar or by the link
on the main page.
To enroll in EFT payment, please complete the following page and return to Scion Dental via:


Fax: 262-721-0722
Email: [email protected]
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ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
PART I – REASON FOR SUBMISSION
Reason for Submission: ❑ New EFT Authorization ❑ Revision to Current EFT setup (e.g. account or bank changes)
PART II – PROVIDER OR SUPPLIER INFORMATION
Name of Payee: ___________________________________________________________________________________
Tax Identification Number: (Designate SSN ❑ or EIN ❑) ___ ___ ___ ___ ___ ___ ___ ___ ___
Address of Payee (City, State, ZIP Code): ________________________________________________________________
PART III – DEPOSITORY INFORMATION (Financial Institution)
Bank/Depository Name__________________________________________________________________________
Depository Routing Transit Number (nine digits — include any leading zeros) ___ ___ ___ ___ ___ ___ ___ ___ ___
Depositor Account Number (up to 10 digits — include any leading zeros) ___ ___ ___ ___ ___ ___ ___ ___ ___
Type of Account (check one) ❑ Checking Account ❑ Savings Account
PART IV – CONTACT INFORMATION
Name of Billing Contact: ________________________________________________________________________
Phone Number of Billing Contact: _________________________________________________________________
Email Address of Billing Contact: _________________________________________________________________
PART V – AUTHORIZATION
I hereby authorize Scion Dental to initiate credit entries, and in accordance with 31 CFR Part 210.6(f) initiate adjustments for
any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above,
hereinafter called the DEPOSITORY, to credit the same to such account. This authorization agreement is effective as of the
signature date below and is to remain in full force and effect until the CONTRACTOR has received written notification from me of
its termination in such time and such manner as to afford the CONTRACTOR and the DEPOSITORY a reasonable opportunity to
act on it. The CONTRACTOR will continue to send the direct deposit to the DEPOSITORY indicated above until notified by me that
I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the
CONTRACTOR an updated EFT Authorization Agreement.
Signature of Authorized Billing Contact: ________________________________________ Date: _________________________
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Provider Enrollment and Contracting Portal
To add new providers and/or locations from your office, visit our provider enrollment portal at scionproviders.com. Enter the
code KS and click the Enter button to continue.
You may also contact Provider Services at 1-855-812-9206 to enroll new providers and/or locations.
Once at the Welcome page in order to view, sign and complete the necessary information, enter the new provider or location’s
NPI number and click submit.
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Statement of Member Rights and Responsibilities
Scion Dental is committed to the following core concepts in its approach to member care:
Access: Access to providers and services
Wellness: Wellness programs, which include member education
and disease management initiatives
Outreach: Outreach programs that educate members and give
them the tools they need to make informed decisions about their
dental care
Feedback: Feedback from members through ongoing member
satisfaction surveys and provider evaluations with Rate a Provider
rankings
Beyond these four core concepts, Scion Dental also believes in the
following set of values. All members have the right to:

Privacy and to be treated with respect and recognition of their
dignity when receiving dental care, which is a private and
personal service

Fully participate with caregivers in the decision-making
process surrounding their health care

Be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the
coverage or cost for the care discussed

Voice a grievance against Scion Dental, or any of its participating dental offices, or any of the care provided by these groups
or people, when their performance has not met the member’s expectations

Appeal any decisions related to patient care and treatment

Make recommendations regarding Scion Dental’s/Healthcare and Family Services’ member rights and responsibilities
policies

Receive pertinent written and up-to-date information about Scion Dental, the services Scion Dental provides, the
participating dentists and dental offices, as well as member rights and responsibilities
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Statement of Provider Rights and Responsibilities
Scion Dental Scion Dental has established the following core concepts in its approach to a positive provider experience:
Access: Access to flexible participation options in provider networks
Outreach: Outreach programs that lower provider participation costs
Technology: Technology tools that increase efficiency and lower
administrative costs
Feedback: Feedback that measures both provider and member
satisfaction
Enrolled participating providers shall have the right to:

Communicate with patients, including members, regarding
dental treatment options

Recommend a course of treatment to a member, even if the
course of treatment is not a covered benefit or approved by
Scion Dental

File an appeal or grievance pursuant to the procedures of Scion
Dental

Supply accurate, relevant and factual information to a member
in conjunction with a grievance filed by the member

Object to policies, procedures or decisions made by Scion Dental
Enrolled participating providers have the following responsibilities:

If a recommended treatment plan is not covered, the participating dentist, if intending to charge the member for the
noncovered services, must notify the member.

A provider wishing to terminate participation with the Scion Dental Network due to retirement, relocation or voluntary
termination must supply written notification of termination to Scion Dental at least 60 days prior to expected final date of
participation. A list of existing Amerigroup patients currently in treatment should accompany the termination notification. All
other Amerigroup patients should be referred to Scion Dental’s toll-free member number 1-855-866-2627 to find another
dentist in their area.

A provider may not bill both medical and dental codes for the same procedure.
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Member Eligibility Verification Procedures and Services to Members
Member Identification Card
Amerigroup members are issued identification cards regularly.
Providers are responsible for verifying members are eligible at the time services are rendered and to determine if members
have other health insurance.
Scion Dental recommends each dental office make a photocopy of the member’s identification card each time treatment is
provided. It is important to note the identification card does not need to be returned should a member lose eligibility.
For additional information concerning member identification cards, please contact Scion Dental’s Provider Relations
department at 1-855-812-9206.
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Scion Dental Eligibility Systems
Enrolled participating providers may access member eligibility information through:

The Providers section of Scion Dental’s website at www.sciondental.com

Scion Dental’s Interactive Voice Response (IVR) system eligibility line at 1-855-812-9206

Scion Dental’s Provider Services department at 1-855-812-9206
The eligibility information received from any of the above sources will be the same information you would receive by calling
Scion Dental’s Provider Services department; however, by utilizing the IVR or the website, you can get information 24 hours a
day, 7 days a week without having to wait for an available Provider Services representative.
Access to eligibility information via www.sciondental.com
Scion Dental’s website currently allows enrolled participating providers to verify a member’s eligibility as well as submit
claims. To access the eligibility information via Scion Dental’s website, simply log on to the website at
www.sciondental.com.
Once you have entered the website, click on Providers. You will then be able to log in using your password and ID. First
time users will have to self-register by utilizing their Scion Dental Payee ID, office name and office address. Please refer
to your payment remittance or contact Provider Services at 1-855-812-9206 to obtain your Payee ID.
Once logged in, select “eligibility look up” and enter the applicable information for each member you are inquiring
about. Verify the member’s eligibility by entering the member’s date of birth, the expected date of service and the
member’s Medicaid Identification Number (sometimes known as the member’s KMAP ID) or last name and first initial.
You are able to check on an unlimited number of patients and can print off the summary of eligibility given by the
system for your records.
Access to eligibility information via the IVR line
To access the IVR, simply call Scion Dental’s Provider Services department at 1-855-812-9206 for eligibility and service
history. The IVR system will be able to answer all of your eligibility questions for as many members as you wish to check.
Once you have completed your eligibility checks or history inquiries, you will have the option to transfer to a Provider
Services representative to answer any additional questions during normal business hours.
Callers will need to enter the appropriate Tax ID or NPI number, the member’s Amerigroup identification number and
date of birth. Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the
information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to verify the
member information you entered, you will be transferred to a Providers Service representative.
Directions for using Scion Dental’s IVR to verify eligibility:
1. Call Scion Dental Provider Services at 1-855-812-9206.
2. When prompted, enter your provider NPI or Tax ID number.
3. Follow the additional prompts and enter member information using the Amerigroup ID number or SSN.
4. When prompted, enter the member’s ID, less any alpha characters that may be part of the ID, or the SSN.
5. When prompted, enter the member’s date of birth in MMDDYYYY format.
6. Upon system verification of the member’s eligibility, you will be prompted to verify the eligibility of another member,
inquire about service history or choose to speak to a Provider Service representative.
Please note, due to possible eligibility status changes, the information provided by either system does not
guarantee payment. If you are having difficulty accessing either the IVR or website, please contact Provider
Services at 1-855-812-9206.
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Transportation Benefits
Members who need assistance with transportation should contact Access2Care of Kansas at 1-855-345-6943.
Appointment Availability Standards
Scion Dental has established appointment time requirements for all situations to ensure members receive dental services in a
time period appropriate to their health condition. Providers should ensure appointment standards are adhered to in an effort to
ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative services such
as an emergency room.

Routine dental care must be scheduled within 21 calendar days (or within the standards for your community).

Urgent care must be scheduled within 48 hours.

Emergent care must be scheduled immediately.
Scion Dental will educate providers about appointment standards, monitor the adequacy of the process and take corrective
action if required.
Scion Dental Provider Manual
Annually, Scion Dental mails (or electronically provides) a provider manual to every dental provider.
Scion Dental Customer Service Numbers:

Customer Service for providers — 1-855-812-9206

Customer Service for members — 1-855-866-2627

TTY service for hearing impaired members — 1-800-508-6975
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Covered Benefits
KanCare Programs Description
Plan Eligibility:
Title 19 Children Ages 0-20
Title 19 Adults Ages 21 and over
Title 21 Children Ages 0-18
Title 19 Children Ages 0-20 and Title 21 Children ages 0-18:
Kancare covers periodic teeth cleaning, fluoride treatment, sealants, tooth restorations, radiographs, extractions, and other
dental services as outlined the benefit tables starting on Page 57.
Title 19 Adults Ages 21 and over:
Kancare covers Extractions only when considered medically necessary. Exam and x-rays are reimbursable only when
performed in conjunction with covered services or to make a diagnosis for such a situation.
Adult Value Added Benefits
Amerigroup Kansas offers two value-added benefits to adult Medicaid members (ages 21 and over).

Cleaning every 6 months using code D1110 (prior approval not required)

Teeth whitening services for discoloration due to genetics, disease, or root damage. Providers should utilize the
below codes which are limited to one per 60 months per arch. Prior approval is required:
D9972- external bleaching per arch
D9973- external bleaching per tooth
D9974- internal bleaching per tooth
Discoloration of teeth due to coffee, tea, cola, or cigarettes will not be covered .
ICF/MR Beneficiaries:
ICF/MR beneficiaries Ages 21 and over are eligible for selected dental services. Refer to the benefit tables starting on p. 57.
KanCare beneficiaries under age 21 residing in an ICF/MR are allowed the full scope of dental services that are allowed for
Title 19 and Title 21 children.
HCBS Adult Ages 65 and Over (not ICR/MR):
Please refer to the Crisis Exception process on Page 29 for details.
Money Follows the Person (MFP):
MFP adult beneficiaries covered through the FE, PD, TBI (or HI) and MR/DD waivers are eligible for dental coverage. Refer to
the benefit tables starting on page 57 for details.
Medically Needy (Spenddown):
In some cases, the income of a family or individual exceeds the income standard to receive public assistance monies.
However, their income is not sufficient to meet all medical expenses. The family group/individual are considered Medically
Needy (MN) and must incur a specified amount of medical expenses before they are eligible for Medicaid benefits. This
process is referred to as spenddown.
Scion does not make payment on the amount that is the beneficiary’s responsibility. Providers can call Scion, or check the
KMAP website, to identify those beneficiaries with a spenddown obligation.
Note: Do not reduce the claim charges or balance due by the spenddown amount. This reduction is made automatically during
claim processing.
A full listing of covered services by benefit plan is outlined in the “Authorization Requirements and Benefit Plan Detail” section
at the end of the manual. The “Authorization Requirements and Benefit Plan Details” provides you with:
 Complete listing of all covered codes
 Description of Retro Claim Review or Prior Authorization Requirement per code
 Listing of documentation required for Retro Claim Review and Prior Authorization submissions
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

Age maximums per each code. Certain services are only covered to a certain age and the maximum age is listed in the
Age Max column of the grid
Additional information regarding coverage or limitations for a specific code
Missed Appointments
Enrolled participating providers are not allowed to charge members for missed appointments.
If your office mails letters to members who miss appointments, the following language may be helpful to include:

“We missed you when you did not come for your dental appointment on month/date. Regular checkups are needed to keep
your teeth healthy.”

“Please call to reschedule another appointment. Call us ahead of time if you cannot keep the appointment. Missed
appointments are very costly to us. Thank you for your help.”
Scion Dental offers the following suggestions to decrease the number of missed appointments.

Contact the member by phone or postcard prior to the appointment to remind the individual of the time and place of the
appointment.
The Centers for Medicare & Medicaid Services (CMS) interpret federal law to prohibit a provider from billing an Amerigroup
member for a missed appointment. In addition, your missed appointment policy for Amerigroup-enrolled patients cannot be
stricter than that of your private or commercial patients.
If an Amerigroup member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient,
please inform them to contact Scion Dental for a referral to a new dentist. Providers with benefit questions should contact Scion
Dental’s Provider Service directly at 1-855-812-9206.
Payment for Noncovered Services
Enrolled participating providers shall hold members, Scion Dental and Amerigroup harmless for the payment of noncovered
services except as provided in this paragraph. Provider may bill a member for noncovered services if the provider obtains an
agreement from the member prior to rendering such service that indicates:

The services to be provided

Scion Dental and Amerigroup will not pay for or be liable for said services

Member will be financially liable for such services
Providers must inform members in advance and in writing that the member is responsible for noncovered services, per K.A.R.
30-5-59 (e)(4).
Electronic Attachments
FastAttach™ — Scion Dental accepts dental radiographs electronically via FastAttach™ for authorization requests and claims
submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA) allows enrolled participating providers
the opportunity to submit all claims electronically, even those requiring attachments. This program allows secure transmissions
via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.
FastAttach™ is the SIMPLE way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow-up with payers
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
Stop sending unnecessary attachments with claims
FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments, and
accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management
systems.
For more information, or to sign up for FastAttach, go to http://www.nea-fast.com or call NEA at 1-800-782-5150.
Crisis Exception Process
The Frail and Elderly waiver population is comprised of two segments; Home and Community Based Services (HCBS) adults ages
65 and over (not ICF/MR) and Money Follows the Person (MFP) adults 65 and over.
Members in the Frail Elderly waiver are eligible for select oral health services above and beyond those dental services that are
covered for all adult Medicaid members. These oral health services include accepted dental procedures, to include diagnostic,
prophylactic, and restorative care, and allow for the purchase, adjustment, and repair of dentures. This includes anesthesia
services provided in the dentist’s office and billed by the dentist. These services do not include outpatient or inpatient facility
care, orthodontic and implant services, or provision of oral health services for cosmetic services.
The MFP Frail and Elderly member’s additional oral health services are limited to the participant’s assessed level of service
need, as defined in the product category. There are no additional benefits beyond those outlined in the benefit tables at the end
of the manual.
The HCBS Frail and Elderly members, additional oral health services are limited to the participant’s assessed level of service
need, provided to the Adult T-19 members. However, additional benefits can be provided subject to a crisis exception process.
In addition to the documentation required for the requested service, please include a narrative of medical necessity. The
narrative should include at a minimum a documented assessment of the member’s oral health and the below information:



Did the member have a treatment plan in place prior to 1/1/2010? If yes, what treatment is left in progress?
Does the member require emergency treatment to resolve an oral health issue that is life threatening?
How will non-treatment of the oral health issue impact the member?
1. “Active Infection”
- soft tissue or bone that
- Causes abscess
- class 3 mobility –(non-restorable tooth)
2. “Inflammation”
- leading to infection (chronic)
- Hygienist treatment
3. Cavity
– infection possible (restore)
4. Chipped tooth/broken tooth
In addition, does the member have:

Diabetes (especially apply to questions 1 & 2)

Doesn’t have denture- only 3 to 4 teeth, lack of ability to eat.

A lack of infection but would rank above cavity/chipped tooth.
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
Only has a few teeth left will risk maintaining good nutrition. 6 teeth on top and 6 teeth on bottom could function
depending on which teeth.

Rate of inflammation to infection differs depending on specific circumstances.
Once the patient is determined to have a life threatening condition, the dental consultant will review the clinical criteria for the
requested services to determine if the requested service is in the best interest of the member.
Code D9999
Dental procedure code D9999, clinical and caries risk assessment, toothbrush prophylaxis of a child ages 0-3 years and
counseling to parents/primary caregiver, will be covered for FQHCs and all dental provider specialties when rendered by a
Registered Dental Hygienist with an Extended Care Permit. Please indicate in the comments section of the ADA Claim Form,
“ECP Risk Assessment 0-3 years of age”.
Orthodontic Services
Orthodontic services are limited to recipients whose disability and impairment to their physical development due to the following
conditions:
 History or current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft
palate)
 Traumatic facial injury substantiated by a medical report (i.e. auto accident) resulting in serious health impairment
(reconstructive surgery etc.)
Exclusions
Scion Dental will not reimburse for:









Treatment primarily for cosmetic purposes
Expanders
Crossbite
Overcrowding of teeth
Over bite / under bite (buck teeth)
Displacement of jaw (TMJ)
Missing teeth or too many teeth
Teeth growing in the palate area
Split phase treatment, with exception of cleft palate cases
Facilities with Encounter Payments (FQHC/RHCs)
All dental services performed by facilities which are reimbursed through encounter payments need to submit an encounter
claim for each unique member visit. The encounter claim is processed to track utilization of HEDIS/EPSDT services. It is
mandatory to submit encounter data per state and federal guidelines. Claims should be submitted with each individual service
rendered. The services will be entered into Scion’s claims payment system for utilization tracking. The actual encounter
payment will be paid utilizing code D0999 which will match your encounter fee as provided by KanCare. You do not have to
include D0999 in your claim submission. Scion’s system automatically performs this function.
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Retrospective Review, Prior Authorization*, and Documentation Requirements
*Prior Authorization is only required for orthodontic, crisis exception and non-participating
provider requests
Retrospective Review
Services that require retrospective review are outlined in the exhibit section at the end of this manual.
Claims that require retrospective review need to be submitted with the appropriate documentation. Types of documentation
required, not limited to, are:

Radiographs (Pre-op, post-op or opposing arch x-rays as indicated in the exhibits)

Narrative of medically necessity

Perio charting
Any claims for retrospective review submitted without the required documents will be denied and must be resubmitted for
reimbursement.
The Scion Dental Consultant reviews the documentation to ensure the services rendered meet the clinical criteria requirements
as outlined in this manual. Once the clinical review is completed, the claim is either paid or denied within 20 calendar days for
clean claims and notification will be sent to the provider via the provider remittance statement.
Procedures Requiring Prior Authorization
Scion Dental must make a decision on a request for prior authorization within 14 calendar days from the date Scion Dental
receives this request, provided all information is complete. If you indicate or we determine that following this time frame could
seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function, we will make an
expedited authorization decision and provide notice of our decision within three business days.
If Scion Dental denies the approval for some or all of the services requested, Scion Dental will send the recipient a written
notice of the reasons for the denial(s) and will tell the member he or she may appeal the decision. The requesting provider will
also receive notice of the decision.
Scion Dental has specific dental utilization criteria as well as a prior authorization and retrospective review process to manage
the utilization of services. Consequently, Scion Dental’s operational focus is on assuring compliance with its dental utilization
criteria.
One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to
authorizing payment for certain procedures. Services requiring prior authorization should not be started prior to the
determination of coverage (approval or denial of the prior authorization) for nonemergency services. Nonemergency treatment
started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied,
the treating dentist will be financially responsible and may not balance bill the member, the state of Kansas or any agents,
and/or Scion Dental.
Prior authorizations will be honored for 180 days from the date they are issued. An approval does not guarantee payment. The
member must be eligible at the time the services are provided. The provider should verify eligibility at the time of service.
Requests for prior authorization should be sent with the appropriate documentation on a standard ADA 2006 approved form.
Any claims or prior authorizations submitted without the required documentation will be denied and must be resubmitted to
obtain reimbursement.
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The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive
service would adequately meet the member’s needs, and whether the proposed item or service conforms to commonly
accepted standards in the dental community. If you have questions regarding a prior authorization decision or wish to speak to
the dental reviewer, you can do so by calling 1-855-812-9206.
Orthodontic Models
Scion Dental does not currently accept orthodontic models as supporting documentation for authorization or claim submissions.
If an orthodontic model is received, Scion will create a copy of all accompanying paperwork, process the authorization and
return the orthodontic model to the dentist per plan guidelines.
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Claim Submission Procedures
Scion Dental receives dental claims directly in three possible formats. These formats include:
1. Electronic claims via Scion Dental’s website (www.sciondental.com)
2. Electronic submission via clearinghouses
3. HIPAA Compliant 837D File
In addition to the three direct billing methods listed above, Scion Dental also receives claims from
KDHE through the Front End Billing process as listed on page 8.
Electronic Claim Submission Utilizing Scion Dental’s Website
Enrolled participating providers may submit claims directly to Scion Dental by utilizing the Provider section of our website.
Submitting claims via the website is very quick and easy and is at no additional cost to providers!
It is especially easy if you have already accessed the site to check a member’s eligibility prior to providing the service.
To submit claims via the website, simply log on to www.sciondental.com.
If you have questions on submitting claims or accessing the website, please contact our Systems Operations department at
1-855-812-9206 or via email at [email protected].
Electronic Claim Submission via Clearinghouse
Dentists may submit their claims to Scion Dental via a clearinghouse such as DentalXChange.
You can contact your software vendor and make certain they have Scion Dental listed as a payer. Your software vendor will be
able to provide you with any information you may need to ensure submitted claims are forwarded to Scion Dental.
Scion Dental’s Payer ID is “SCION” — DentalXChange will ensure that by utilizing this unique payer ID, claims will be submitted
successfully to Scion Dental.
For more information on DentalXChange, please refer to their website at www.dentalxchange.com.
HIPAA Compliant 837D File
For providers who are unable to submit electronically via the Internet or a clearinghouse, Scion Dental will work on a case-bycase basis with the provider to receive claims electronically via a HIPAA Compliant 837D file from the provider’s practice
management system. Please contact Customer Care at 1-855-812-9206 or via email at [email protected] to inquire
about this option for electronic claim submission.
Paper Claim Submission
Paper claims not for retro review submitted directly to Scion will be returned to the provider and not processed. Providers
submitting claims via Front End Billing must ensure they are providing the following information:

Member’s Medicaid ID – This is sometimes knows as the KMAP ID. This is listed on the Amerigroup member ID cards
as “Medicaid or CHIP number.” Providers should not use the Amerigroup ID when submitting claims via the Front End
Billing process as these claims will reject. The state forwards these claims to Scion based on the Medicaid ID and
claims submitted with the Amerigroup ID will be rejected.

Provider NPI (not the KMAP Provider ID)
o
This applies to web, electronic and paper claims.
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o
Claims without this information may be rejected or denied by Scion and/or HPES.
Please see KMAP General Bulletin 12115 https://www.kmap-state-ks.us/Documents/Content/Bulletins/12115%20-%20General%20%20KanCare%20FEB.pdf) for more information.
Corrected Claim Process
Providers who receive a claim denial and need to submit a corrected claim should submit a corrected claim and appropriate
documentation if necessary to:
P.O. Box 1448
Milwaukee, WI 53201
You can request for an additional claim review, if a claim was denied due to missing information, missing tooth number/surface
on the orginial submission or you have additional information you feel may change the claim payment decision. The
determinaton of a corrected claim request, will be provided an a remittance statement within 30 days of receipt.
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Authorization Submission Procedures
Authorizations must be submitted on 2006 ADA approved claim forms or other forms approved in advance by Scion Dental.
Please reference the ADA website for the most current claim form and completion instructions. Forms are available through the
American Dental Association at:
American Dental Association
211 E. Chicago Ave.
Chicago, IL 60611
1-800-947-4746
Member name, Medicaid Identification Number and date of birth must be listed on all claims submitted. If the member
Medicaid Identification Number is missing or miscoded on the claim form, the patient cannot be identified. This could result in
the claim being returned to the submitting provider office, causing a delay in payment.
The provider and office location information must be clearly identified on the claim. Frequently, if only the dentist signature is
used for identification, the dentist’s name cannot be clearly identified. To ensure proper claim processing, the claim form must
include the following:

The treating provider’s name

The location in which the treatment occurred

The billing (business office) location

The treating provider’s Kansas Medicaid ID number, NPI or Tax Identification Number (TIN)
The date of service must be provided on the claim form for each service line submitted.
Approved ADA dental codes as published in the current CDT book or as defined in this manual must be used to define all
services.
Provider must list all quadrants, tooth numbers and surfaces for dental codes that necessitate identification (extractions, root
canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim
payment.
Scion Dental recognizes tooth letters A through T for primary teeth and tooth numbers 1 to 32 for permanent teeth.
Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be
determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is #1 then the supernumerary
tooth should be charted as #51; likewise, if the nearest tooth is A the supernumerary tooth should be charted as AS. These
procedure codes must be referenced in the patient’s file for record retention and review. Patient records must be kept for a
minimum of seven years.
All dental services performed must be recorded in the patient record, which must be available as required by your Provider
Services Agreement.
Affix the proper postage when mailing bulk documentation. Scion Dental does not accept postage due mail. This mail will be
returned to the sender and will result in delay of payment.
Paper Authorizations should be mailed to the following address:
Scion Dental of Kansas – Authorizations
P.O. Box 1225
Milwaukee, WI 53201
33
34
35
Claims Adjudication and Payment
Scion Dental’s system adjudicates all claims weekly. It also has the ability to automatically update individual and family claim
history, perform claim payment calculations, calculate and update copayment/deductible accumulations, and track benefit
maximums and frequency limits where appropriate.
The Claim Adjudication Module (CAM) serves as Scion Dental’s primary claims processing tool. Scion Dental’s Claims
Adjudication Module imports the data, edits the data for completeness and correctness, analyzes the data for clinical and
coding correctness/appropriateness, and audits against product and benefit limits. CAM also will review claims/services that
require preauthorizations and automatically match the claim/service to the appropriate member record for efficient claims
processing.
Claims will be finalized weekly on Fridays and once all CAM edits are complete, claims are priced, a remittance summary is
printed, and a check or EFT payment is generated. You will be able to review the status of claims submissions once finalized on
Scion’s Provider Web Portal or via electronic submission.
Coordination of Benefits (COB)
When Scion Dental is the secondary insurance carrier, a copy of the primary carrier’s EOB must be submitted with the claim. For
electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a
primary carrier’s payment meets or exceeds a provider’s contracted rate or fee schedule, Scion Dental will consider the claim
paid in full and no further payment will be made on the claim.
*NOTE* Scion Dental follows KMAP TPL policy. All KMAP TPL billing requirements still apply. Please refer to KMAP General TPL
Payment provider manual. Clarification to this provider manual will be added at a later date.
Filing Limits
The timely filing requirement for services rendered to Amerigroup members is 180 calendar days from the date of service and
receipt of claim. Scion Dental determines whether a claim has been filed timely by comparing the date of service to the receipt
date applied to the claim when the claim is received. If the span between these two dates exceeds the time limitation, the claim
is considered to have not been filed timely.
Receipt and Audit of Claims
In order to ensure timely, accurate remittances to each dentist, Scion Dental performs an edit of all claims upon receipt. This
edit validates member eligibility, procedure codes and provider identifying information. A Dental Reimbursement Analyst
dedicated to Kansas dental offices analyzes any claim conditions that would result in nonpayment. When potential problems are
identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Scion Dental’s
Provider Services at 1-855-812-9206 with any questions you may have regarding claim submission or your remittance.
Each enrolled participating provider office receives an EOB report with its remittance. This report includes member information
and an allowable fee by date of service for each service rendered during the period.
If a dentist wishes to appeal any reimbursement decision, the dentist needs to submit an appeal in writing along with any
necessary additional documentation within 33 days to:
P.O. Box 1448
Milwaukee, WI 53201
Scion Dental will have 30 days to respond in writing to the dentist with outcome of the appeal. This notice will contain the
information necessary to appeal this decision. To validate accuracy, on a monthly basis Scion Dental will perform an audit of a
statistically significant sample of all the claim forms entered and adjudicated in the prior month.
36
Inquiries, Grievances and Appeals
Scion Dental is committed to providing high-quality dental services to all members. As part of this commitment, Scion Dental
supports Amerigroup Kansas’s member grievances and appeals protocol and leads Amerigroup KS’s dental provider complaint
protocol that assures all members have every opportunity to exercise their rights to a fair and expeditious resolution to any and
all inquiries, grievances and appeals. Toward that end, Scion Dental has developed a procedure to meet the following goals:

To ensure Scion assists in members and providers receiving a fair, just and speedy resolution to inquiries, grievances and
appeals, by working with providers and: providing any documentation related to the member grievance and /or appeal to
Amerigroup Kansas, upon request.

To allow providers and members to be treated with dignity and respect at all levels of the grievances and appeals resolution
process

To inform providers of their full rights as they relate to grievances and appeals resolution, including their rights of appeal at
each step in the process

To have provider grievances and appeals resolved in a satisfactory and acceptable manner within the Scion Dental protocol

To comply with all regulatory guidelines and policies with respect to member inquiries, grievances and appeals

To efficiently track the resolution of provider-related grievances, so as to be able to track continuing unacceptable patterns
of care over time
Scion Dental provides customer service, the primary purpose of which is to ensure provider access to information, services and
assistance on issues affecting their coverage. The designated complaint coordinator is dedicated to the expedient, satisfactory
resolution of provider inquiries, grievances and appeals.
The toll-free number to call to file a provider grievance is 1-855-812-9206.
The address to file a provider grievance:
Scion Dental of Kansas – Grievance
P.O. Box 1448
Milwaukee, WI 53201
Appeals
Member Appeals
Members must file an appeal within 33 days following the date the denial letter was mailed by Scion Dental. Member
requests for an appeal must be submitted in writing to:
P.O. Box 1448
Milwaukee, WI 53201
A member may appeal any Scion Dental decision that denies or reduces services. Such appeals will be reviewed by
Scion Dental under its existing administrative appeal procedure.
Members can request a State Fair Hearing at any time during the appeals process. The request must be submitted to
the Office of Administrative Hearings so it is received within 33 days of receipt of the letter with our decision. The
request should be mailed to:
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1020 S. Kansas Ave.
Topeka, KS 66612-1327
The matter will be heard before an Administrative Hearing Officer. Scion Dental will provide and pay for any services
which any jurisdiction orders rendered, provided the member is eligible. Scion Dental shall make expert testimony
available.
Dentist Appeal Procedures
In the operation of the program, differences may develop between Scion Dental and the dentist concerning the decision
regarding the Prior Authorization Option and payment for service. Since many of these problems result from
misunderstanding of processing policy, service coverage or payment levels, thorough acquaintance with Scion Dental
will help prevent such problems.
To request an appeal, the provider should write:
P.O. Box 1448
Milwaukee, WI 53201
Fair Hearing Procedures
If a provider disagrees with a decision Scion Dental has made on a claim, the provider has the right to request a fair
hearing within 33 days of Scion’s final decision. All provider appeal rights must be exhausted prior to requesting a fair
hearing. There is not a required form but the request needs to be sent in writing to:
1020 S. Kansas Ave.
Topeka, KS 66612-1327
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Health Insurance Portability and Accountability Act (HIPAA)
As a health care provider, if you transmit any health information electronically your office is required to comply with all aspects
of the Health Insurance Portability and Accountability Act (HIPAA) regulations that have gone/will go into effect as indicated in
the final publications of the various rules covered by HIPAA.
Scion Dental has implemented various operational policies and procedures to ensure it is compliant with the Privacy Standards
as well. Scion Dental also intends to comply with all Administrative Simplification and Security Standards by their compliance
dates. One aspect of our compliance plan will be working cooperatively with providers to comply with the HIPAA regulations.
The provider and Scion Dental agree to conduct their respective activities in accordance with the applicable provisions of HIPAA
and such implementing regulations.
When contacting Provider Services, providers will be asked to provide their Tax ID or NPI number. When calling regarding
member inquiries, providers will be asked to provide specific member identification such as member ID/SSN, date of birth,
name and/or address.
In regulation to the Administrative Simplification Standards, you will note the benefit tables included in this provider manual
reflect the most current coding standards (CDT-2010) recognized by the ADA. Effective the date of this manual, Scion Dental will
require providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be
submitted on the current approved ADA 2006 claim form.
Note: Copies of Scion Dental’s HIPAA policies are available upon request by contacting Scion Dental’s Provider Services at
1-855-812-9206 or via email at [email protected].
39
Utilization Management Program
Introduction
Reimbursement to dentists for dental treatment rendered can come from any number of sources such as individuals,
employers, insurance companies and local, state or federal government. The source of dollars varies depending on the
particular program. For example, in traditional insurance, the dentist reimbursement is composed of an insurance payment and
a patient coinsurance payment. This Kansas State Legislature annually appropriates or “budgets” the amount of dollars
available for reimbursement to dentists for treating Amerigroup members. Since there is usually no patient copayment, these
dollars represent all the reimbursement available to the dentist. The fair and appropriate distribution of these limited funds is
critical.
Community Practice Patterns
To ensure fair and appropriate reimbursement, Scion Dental has developed a philosophy of Utilization Management that
recognizes the fact that there exists, as in all health care services, a relationship between the dentist’s treatment planning,
treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community
practice patterns” of local dentists and their peers. With this in mind, Scion Dental’s Utilization Management programs are
designed to ensure the fair and appropriate distribution of health care dollars as defined by the regionally based community
practice patterns of local dentists and their peers.
All utilization management analysis, evaluations and outcomes are related to these patterns. Scion Dental’s Utilization
Management programs recognize there is individual dentist variance within these patterns among a community of dentists and
accounts for such variance. Also, specialty dentists are evaluated as a separate group and not with general dentists since the
types and nature of treatment may differ.
Evaluation
Scion Dental’s Utilization Management programs evaluate claims submissions in such areas as:

Diagnostic and preventive treatment

Patient treatment planning and sequencing

Types of treatment

Treatment outcomes

Treatment cost effectiveness
Results
With the objective of ensuring the fair and appropriate distribution of these budgeted Scion Dental dollars to dentists, Scion
Dental’s Utilization Management programs helps identify dentists whose patterns show significant deviation from the normal
practice patterns of the community of their peers (typically less than 5 percent of all dentists). Scion Dental is contractually
obligated to report suspected fraud, abuse or misuse by members and participating dental providers to the Amerigroup Office of
the Inspector General.
40
Non-Incentivization Policy
It is Scion’s practice to ensure our contracted providers are making treatment decisions based upon individual members’
medical necessity. Providers are never offered, nor will they ever accept, any kind of financial incentives or any other
encouragement to influence their treatment decisions.
Scion’s Utilization Management department bases their decision-making only on appropriateness of care, service and existence
of coverage. Scion Dental does not specifically reward practitioners or other individuals for issuing denials of coverage or care. If
financial incentives exist for Utilization Management decision makers, they do not include or encourage decisions that result in
underutilization.
Fraud and Abuse
Scion Dental is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as:
Fraud:
Intentional deception or misrepresentation made by a person with knowledge the deception could result in some
unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under federal or state
law.
Abuse:
Requesting payment for items and services when there is no legal entitlement to payment. Unlike fraud, the provider
has not knowingly and/or intentionally misrepresented facts to obtain.
Provider Fraud:
Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost
to the program, or in reimbursement for services that are not medically necessary or fail to meet professionally
recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the program.
Deficit Reduction Act of 2005: The False Claims Act
On February 8, 2006, President Bush signed into law the Deficit Reduction Act of 2005 (DRA), a bill designed to reduce federal
spending on entitlement programs over five years. The DRA requires any entity that receives or makes annual Medicaid
payments of at least $5 million establish written policies for its employees, management, contractors and agents regarding the
False Claims Act (FCA).
The FCA allows private persons to bring a civil action against those who knowingly submit false claims. If there is a recovery in
the case brought under the FCA, the person bringing the suit may receive a percentage of the recovered funds.
For the party found responsible for the false claim, the government may seek to exclude them from future participation in
federal health care programs or impose additional obligations against the individual.
For more information about the False Claims Act go to: www.TAF.org
Scion Dental is contractually obligated to report suspected fraud, waste or abuse by members and participating dental providers
of the Amerigroup Dental Program.
To report suspected fraud, waste or abuse of the Scion Dental Program contact Scion Dental’s confidential fraud hotline at
1-877-378-5292.
41
Credentialing
As required by law, any DDS or DMD who is interested in participation with Scion Dental is invited to apply and submit a
credentialing application form for review by the Scion Dental’s Credentialing Committee. Scion Dental, in conjunction with the
plan, has the sole right to determine which dentists it shall accept and continue as participating providers.
Providers who seek participation in any Scion Dental Managed Care network must be credentialed prior to participation in the
network. Scion Dental will not differentiate or discriminate in the treatment of providers seeking credentialing on the basis of
race, ethnicity, sex, age, national origin or religion.
All applications reviewed by Scion Dental must satisfy NCQA and/or URAC standards of credentialing as they apply to dental
services.
The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing
Committee determines an application should be accepted with restriction or declined, it shall recommend the appropriate
action to the Executive Subcommittee for approval.
In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing
Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board,
government agency or any other organization or institution; or recommend any other action it deems appropriate.
Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for
final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts
the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as any
additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the
Credentialing Committee’s recommendation, the Peer Review Committee will complete the review.
Any acceptance of an applicant is conditioned upon the applicant’s execution of a participation agreement with Scion Dental.
The plan retains the ultimate responsibility for Scion Dental’s credentialing process and final credentialing decisions. The plan is
notified of any terminations or disciplinary actions.
To begin credentialing, providers should go to credentialingportal.com and choose the appropriate state the application will be
effective for.
42
43
44
45
Important Notice for Submitting Paper Authorizations and Claims
In order to maintain HIPAA compliance, effective with claims received October 1, 2010, only ADA 2006 Dental Claim forms will
be accepted when submitting claims and prior authorizations.
All other forms, including ADA forms dated prior to 2006, will not be accepted and will result in a rejection of the claim or prior
authorization request.
Additionally, when making a correction to a previously submitted claim, please send it clearly marked “Corrected Claims” on ADA
2006 forms to the Appeals mailbox.
Please contact the Provider Service toll-free number if you have questions. If you are in need of the current forms, please visit
the ADA website at www.ada.org for ordering information.
Clean claims include the following:

Member name

Member date of birth

Member Medicaid ID number

Treating provider

Payee (billing provider)

Tax ID number

NPI Number

Date of service

Location of service

Procedure code
Claims with missing or invalid information may be rejected and returned to the provider.
Clean authorizations include the following:

Member name

Member date of birth

Member Medicaid ID number

Treating provider

Payee and location

Procedure code
Authorizations with missing or invalid information may be rejected and returned to the provider.
46
Health Guidelines — Ages 0–18 Years
Recommendations for Pediatric Oral Health Assessment, Preventive Services and Anticipatory Guidance/Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical
conditions and are developing normally. These recommendations will need to be modified for children with special health care
needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD)
emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs
of the child.
Refer to the text of guideline on the following page for supporting information and references.
47
48
Kansas Clinical Criteria for Retro-Review and Prior Authorization of Treatment
and Emergency Treatment
Some procedures require retrospective review (after treatment is performed) or prior authorization (before initiating treatment),
when requesting these procedures, please note the documentation requirements when sending in the information to Scion
Dental. The criteria Scion Dental reviewers will look for in order to approve the request is listed below. Scion Dental criteria
utilized for this medical necessity determination were developed from information collected from American Dental Association's
Code Manuals, clinical articles and guidelines, as well as dental schools, practicing dentists, insurance companies, other dental
related organizations, and local state or health plan requirements.If there is any question that a procedure that is subject to
retro-review may not meet criteria and may not be paid, you have the option of submitting the procedure for prior authorization
first.
Radiographs/Diagnostic Imaging

Documentation describes medical necessity
Other Temporomandibular Joint Films, by Report

Documentation describes medical necessity
Crowns/Onlays/Coping- Retro-Review







Minimum 50 percent bone support
No periodontal furcation
No subcrestal caries
Clinically acceptable RCT
Anterior – 50 percent incisal edge/4+ surfaces involved
Bicuspid – 1 cusp/3+ surfaces involved
Molar – 2 cusps/4+ surfaces involved
Cast Posts and Cores/Prefabricated Post and Cores- Retro-Review




Clinically acceptable RCT
Pulpotomy/Debridement/Pulp Therapy/Regeneration- Retro-Review

Documentation supports procedure
Root Canals- Retro-Review






Evidence of apical pathology/fistula
Pain from percussion/temp
Closed apex
Treatment of Root Canal Obstruction- Retro-Review

Documentation supports procedure
49
Apexification- Retro-Review





Evidence of apical pathology/fistula
Evidence of deep caries/restoration, fracture, near pulpal exposure with open apex
Pain from percussion or temperature with open apex
Fill X-ray with claim (final visit)
Apicoectomy/Periradicular Services- Retro-Review




History of RCT
Apical pathology
No caries below bone level
Gingivectomy or Gingivoplasty- Retro-Review


Hyperplasia or hypertrophy from drug therapy, hormonal disturbances or congenital defects
Generalized 5 mm or more pocketing indicated on the perio charting
Anatomical Crown Exposure- Retro-Review

Documentation supports procedure, need to remove tissue/bone to provide anatomically correct gingival relationship
Surgical Revision - Retro-Review

Documentation supports need to refine results of previous surgical procedure
Scaling and Root Planning- Retro-Review


D4341
 Four or more teeth in the quadrant
 5 mm or more pocketing on two or more teeth indicated on the perio charting
 Presence of root surface calculus and/or noticeable loss of bone support on X-rays
D4342
 One to three teeth in the quadrant
 5 mm or more pocketing on one or more teeth indicated on the perio charting
 Presence of root surface calculus and/or noticeable loss of bone support on X-rays
Full Dentures- Retro-Review


Existing denture greater than 5 years old
Remaining teeth do not have adequate bone support or are restorable
Partial Dentures- Retro-Review





Replacing one or more anterior teeth
Replacing two or more posterior teeth unilaterally (excluding third molars)
Replacing three or more posterior teeth bilaterally (excluding third molars)
Existing partial denture greater than 5 years old
Remaining teeth have greater than 50 percent bone support and are restorable
Unilateral Partial Denture- Retro-Review



Replacing one or more missing teeth in one quadrant
Existing partial denture greater than 5 years old
Remaining teeth have greater than 50 percent bone support and are restorable
50
Tissue Conditioning- Retro-Review

Date of service
Implant Removal, by Report- Retro-Review

Documentation describes medical necessity for surgical removal of an implant
Surgical Removal of Erupted Tooth- Retro-Review





Greater than 50 percent bone support
Periapical pathology or furcation involvement
Gross carious lesion or large existing restoration
Curved or dilacerated root
Elevation of flap and/or removal of bone and/or sectioning of tooth
Impacted Teeth (Asymptomatic Impactions will not be approved) - Retro-Review




Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in the patient
record
Tooth impinges on the root of an adjacent tooth, is horizontal impacted, or shows a documented enlarged tooth follicle or
potential cystic formation
Documentation supports procedure for unusual surgical complications
X-rays match type of impaction code described
Surgical Removal of Residual Tooth Roots- Retro-Review


Tooth root is completely covered by tissue on X-ray
Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in the patient
record
Oroantral Fistula Closure/Sinus Perforation- Retro-Review

Due to extraction, oral infection or sinus infection
Surgical Access of an Unerupted Tooth- Retro-Review


Documentation supports impacted/unerupted tooth
Tooth is beyond one year of normal eruption pattern
Biopsy- Retro-Review

Copy of pathology report with claim
Alveoloplasty without Extractions- Retro-Review

Necessary for fabrication of a prosthesis
Vestibuloplasty- Retro-Review

Documentation supports lack of ridge for denture placement
Excision of Bone Tissue- Retro-Review

Necessary for fabrication of a prosthesis
Maxillary Sinusotomy- Retro-Review

Documentation describes presence or description of root fracture of foreign body in maxillary antrum
51
Fractures – Simple/Compound- Retro-Review

Documentation describes accident, operative report and medical necessity
Reduction and Dislocation and Management of TMJ Dysfunctions- Retro-Review

Narrative, X-rays or photos support medical necessity for procedure
Skin Graft- Retro-Review

Documentation describes location and type of graft
Other Repair Procedures (Oral and Maxillofacial Surgery) - Retro-Review

Narrative, X-rays or photos support medical necessity for procedure
Frenulectomy- Retro-Review

Documentation describes tongue tied, diastema or tissue pull condition
Frenuloplasty- Retro-Review

Documentation indicates frenum will be repositioned instead of being excised
Excision of Pericoronal Gingiva- Retro-Review


Documentation shows tissue partially covers occlusal surface of crown
Documented history of repeat infections
Regional/Trigeminal Division Block Anesthesia- Retro-Review

Documentation describes medical necessity for procedure beyond local anesthesia with claim
General Anesthesia/IV Sedation (Dental Office Setting) – One or more of the criteria below- Retro-Review









Extractions of impacted or unerupted cuspids or wisdom teeth or surgical exposure of unerupted cuspids
Two or more extractions in two or more quadrants
Four or more extractions in one quadrant
Excision of lesions greater than 1.25 cm
Surgical recovery from the maxillary antrum
Documentation showing the patient is younger than 9 years old with extensive treatment (described)
Documentation of failed local anesthesia and documentation noted in patient record
Documentation of situational anxiety and documentation noted in patient record
Documentation and narrative of medical necessity supported by submitted medical records (cardiac, cerebral palsy,
epilepsy or condition that would render patient noncompliant)
Inhalation of Nitrous Oxide/Analgesia- Retro-Review

Documentation describes medical necessity for procedure with claim
Hospital Call- Retro-Review

Documentation of time spent and reason for hospital call
Therapeutic Drug Injection- Retro-Review

Description of drugs (antibiotics, steroids, anti-inflammation or other therapeutic medication) and parental administration
Behavior Management, by Report- Retro-Review

Documentation (treatment history) supports indication of noncooperative child under the age of 9 years
52

Documentation supports indication of patient with a medical condition (cardiac, cerebral palsy, epilepsy, or other condition
that would render the patient noncompliant
Bleaching – Per Arch-Prior-Authorization

Documentation indicates systemic induced staining due to taking of certain medications (i.e. tetracycline, etc.) over time
Bleaching – Per Tooth-Prior-Authorization

Documentation indicates single or multiple endo-treated teeth that have become discolored and there is no planned crowns
Unspecified Procedures, by Report- Retro-Review

Procedure cannot be adequately described by an existing code
Orthodontics-Prior-Authorization
For all orthodontic treatment listed below:


History or a current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft
palate)
Traumatic facial injury substantiated by a medical report (i.e., auto accident) resulting in serious health impairment
(reconstructive jaw surgery, etc.)
Fixed or removable appliance therapy
Limited interceptive treatment
Comprehensive
Pre-orthodontic Treatment Visit (Ortho Records) -Prior-Authorization

Reimbursed only for denied treatment requests
53
AGP_KanCare CHIP - Title 21 Child (0-18)
AUTHORIZATION REQUIREMENTS
Product
AGP_KanCare
CHIP (0-18)
Code
D0120
Code Description
Periodic Oral Evaluation Established Patient
AGP_KanCare
CHIP (0-18)
D0140
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
1
Period
Length
6
Period
Type
MONTH
No
N/A
Age Min
0
ADDITIONAL NOTES
Only one exam every 6
months per provider or
provider billing group.
Only one exam
(D0120,D0140, D0145,
D0150, D0170) per date
of service, per
beneficiary, per provider
or provider billing group.
(D0140 is not limited to 1x
every 6 months)
Limited Oral Evaluation Problem Focused
No
N/A
0
18
D0145
Oral Evaluation, Patient Under
Three
No
N/A
0
2
1
6
MONTH
Only one exam (D0120,
D0140, D0145, D0150,
D0170) per date of
service, per beneficiary,
per provider or provider
billing group. (D0140 is
not limited to 1x every 6
months)
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
0
18
1
6
MONTH
One comprehensive
exam per beneficiary, per
provider or provider billing
group per lifetime. Only
one exam (D0120,
D0145, or D0150) every
six months per
D0140, D0145, D0150,
D0170) per date of
billing group. Limited oral
evaluation is only covered
when performed in
conjunction with
treatment to address an
emergency situation. An
emergency is defined as
treatment medically
necessary to treat pain,
infection, swelling,
uncontrolled bleeding, or
traumatic injury. (D0140
is not limited to 1x every 6
months)
Product
AGP_KanCare
CHIP (0-18)
Code
D0170
Code Description
Re-Evaluation - Limited,
Problem Focused
AGP_KanCare
CHIP (0-18)
D0210
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
1
Period
Length
12
Period
Type
MONTH
MONTH
One per 36 months. The
following are also
considered an Intraoral
Complete Series (D0210)
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
DAYS
One per day. Any
additional films (D0220 D0340) performed on the
same date of service as a
complete intraoral series,
or its equivalent, are
considered content of
service of the complete
series and will not be
reimbursed.
No
N/A
Age Min
0
Intraoral - Complete Series
(Including Bitewings)
No
N/A
0
18
1
36
D0220
Intraoral - Periapical First Film
No
N/A
0
18
1
1
AGP_KanCare
CHIP (0-18)
D0230
Intraoral - Periapical Each
Additional Film
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D0240
Intraoral - Occlusal Film
No
N/A
0
18
ADDITIONAL NOTES
One per 12 months.
Established beneficiary to
access the status of a
previously existing
condition (not postoperative visit). Not
covered with any other
procedure other than
radiographs.
Any additional films
(D0220 - D0340)
performed on the same
date of service as a
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
Product
AGP_KanCare
CHIP (0-18)
Code
D0250
Code Description
Extraoral - First Film
AGP_KanCare
CHIP (0-18)
D0260
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
No
N/A
Age Min
0
Age Max
18
Extraoral - Each Additional
Film
No
N/A
0
18
D0270
Bitewing - Single Film
No
N/A
0
18
D0272
Bitewings - Two Films
No
N/A
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
Only one bitewing code
(D0270, D0272, D0273,
of service, per
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
Product
AGP_KanCare
CHIP (0-18)
Code
D0273
Code Description
Bitewings - Three Films
Auth Required
No
AGP_KanCare
CHIP (0-18)
D0274
Bitewings - Four Films
AGP_KanCare
CHIP (0-18)
D0277
Vertical Bitewings - 7 To 8
Films
Reqd Docs
BENEFIT DETAILS
Max
Count
Period
Length
Period
Type
N/A
Age Min
0
Age Max
18
ADDITIONAL NOTES
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
No
N/A
0
18
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
No
N/A
0
18
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
Product
AGP_KanCare
CHIP (0-18)
Code
D0290
Code Description
Posterior - Anterior Or Lateral
Skull And Facial Bone Survey
Film
AGP_KanCare
CHIP (0-18)
D0321
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
Period
Length
Period
Type
No
N/A
Age Min
0
Other Temporomandibular
Joint Films, By Report
No
N/A
0
18
D0322
Tomographic Survey
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D0330
Panoramic Film
No
N/A
0
18
1
36
AGP_KanCare
CHIP (0-18)
D0460
Pulp Vitality Tests
No
N/A
0
18
3
1
DAYS
AGP_KanCare
CHIP (0-18)
D1110
Prophylaxis - Adult
No
N/A
13
18
1
6
MONTH
AGP_KanCare
CHIP (0-18)
D1120
Prophylaxis - Child
No
N/A
0
12
1
6
MONTH
MONTH
ADDITIONAL NOTES
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
Maximum of three teeth
per visit. Covered teeth
are:
1 - 32, 51 - 82 (SN), A - T,
AS - TS (SN)
One per six months.
Includes scaling and
polishing procedures to
remove coronal plaque,
calculus, and stains.
One per six months.
BENEFIT DETAILS
N/A
Age Min
0
Age Max
18
Max
Count
3
Period
Length
12
Period
Type
MONTH
No
N/A
0
18
3
12
MONTH
Sealant - Per Tooth
No
N/A
0
18
1
12
MONTH
D1510
Space Maintainer - Fixed Unilateral
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D1515
Space Maintainer - Fixed Bilateral
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D1525
Space Maintainer Removable - Bilateral
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D1550
Re-Cementation Of Space
Maintainer
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D2140
Amalgam - One Surface,
Primary Or Permanent
No
N/A
0
18
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
CHIP (0-18)
D2150
Amalgam - Two Surfaces,
No
N/A
0
18
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
CHIP (0-18)
D2160
Amalgam - Three Surfaces,
No
N/A
0
18
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
Product
AGP_KanCare
CHIP (0-18)
Code
D1206
Code Description
Topical Fluoride Varnish
Auth Required
No
AGP_KanCare
CHIP (0-18)
D1208
Topical Application Of Fluoride
AGP_KanCare
CHIP (0-18)
D1351
AGP_KanCare
CHIP (0-18)
Reqd Docs
ADDITIONAL NOTES
Sealants are
reimbursable when
placed on the occlusal or
occlusal-buccal surfaces
of lower 1st and 2nd
permanent molars or
upper 1st and 2nd
permanent molars as well
as permanent upper and
lower bicuspids. Teeth
must be caries free.
Sealant is not covered
when placed over
restorations.
1 per 12 months per
quadrant.
10 (UR)
20 (UL)
30 (LL)
40 (LR)
1 per 12 months per arch.
01 (UA)
02 (LA)
01 (UA)
02 (LA)
Not covered within 6
months of initial
placement within
quadrant or arch.
10 (UR)
20 (UL)
30 (LL)
40 (LR)
01 (UA)
02 (LA)
Product
AGP_KanCare
CHIP (0-18)
Code
D2161
Code Description
Amalgam - Four Or More
Surfaces, Primary Or
Permanent
AGP_KanCare
CHIP (0-18)
D2330
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
1
Period
Length
12
Period
Type
MONTH
No
N/A
Age Min
0
ADDITIONAL NOTES
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
Resin-Based Composite - One
Surface, Anterior
No
N/A
0
18
1
12
MONTH
D2331
Resin-Based Composite - Two
Surfaces, Anterior
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D2332
Resin-Based Composite Three Surfaces, Anterior
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D2335
Resin-Based Composite Four Or More Surfaces Or
Involving Incisal Angle
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D2390
Resin-Based Composite
Crown, Anterior
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D2391
Surface, Posterior
No
N/A
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D2392
Surfaces, Posterior
No
N/A
0
18
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
S, T, AS (SN), BS (SN),
IS - LS (SN), SS (SN),TS
(SN)
AGP_KanCare
CHIP (0-18)
D2393
Resin-Based Composite Three Surfaces, Posterior
No
N/A
0
18
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
M - R, CS - HS (SN), MS
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
Product
AGP_KanCare
CHIP (0-18)
Code
D2394
Code Description
Resin-Based Composite Four Or More Surfaces,
Posterior
AGP_KanCare
CHIP (0-18)
D2710
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Min
0
Age Max
18
Max
Count
1
Period
Length
12
Period
Type
MONTH
ADDITIONAL NOTES
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
No
N/A
Crown - Resin-Based
Composite (Indirect)
Yes-Retro Review
Preoperative radiographs of
adjacent and opposing teeth. If
a tooth has had RCT, a
postendodontic radiograph is
also required showing the
entire tooth, with claim.
0
18
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
D2740
Crown - Porcelain/Ceramic
Substrate
Yes-Retro Review
entire tooth, with claim
0
18
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
D2751
Crown - Porcelain Fused To
Predominantly Base Metal
Yes-Retro Review
0
18
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D2752
Code Description
Noble Metal
Auth Required
Yes-Retro Review
Reqd Docs
Age Min
0
Age Max
18
Max
Count
1
Period
Length
60
Period
Type
MONTH
AGP_KanCare
CHIP (0-18)
D2783
Crown - 3/4 Porcelain/Ceramic
Yes-Retro Review
0
18
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D2791
Crown - Full Cast
Yes-Retro Review
0
18
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
Product
AGP_KanCare
CHIP (0-18)
Code
D2792
Code Description
Crown - Full Cast Noble Metal
Auth Required
Yes-Retro Review
Reqd Docs
AGP_KanCare
CHIP (0-18)
D2910
Recement Inlay, Onlay, Or
Partial Coverage Restoration
No
AGP_KanCare
CHIP (0-18)
D2920
Recement Crown
AGP_KanCare
CHIP (0-18)
D2930
AGP_KanCare
CHIP (0-18)
BENEFIT DETAILS
Max
Count
1
Period
Length
60
Period
Type
MONTH
Age Min
0
Age Max
18
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
N/A
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
No
N/A
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
Prefabricated Stainless Steel
Crown - Primary Tooth
No
N/A
0
18
1
24
MONTH
Teeth Covered:
A-T
AS - TS (SN)
D2930 and D2934 cannot
be placed on the same
tooth during a 24-month
period.
D2931
Crown - Permanent Tooth
No
N/A
0
18
1
24
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D2934
Prefabricated Esthetic Coated
Stainless Steel Crown Primary Tooth
No
N/A
0
18
1
24
MONTH
Teeth Covered:
C - H, M -R
CS - HS (SN)
MS - RS (SN)
tooth during the 24-month
period.
AGP_KanCare
CHIP (0-18)
D2940
Protective Restoration
No
N/A
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
Temporary restoration
intended to relieve pain.
Not to be used as a base
or liner under a
restoration.
Product
AGP_KanCare
CHIP (0-18)
Code
D2951
Code Description
Pin Retention - Per Tooth, In
Addition To Restoration
AGP_KanCare
CHIP (0-18)
D2954
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Min
0
Age Max
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
No
N/A
Prefabricated Post And Core
In Addition To Crown
Yes-Retro Review
Pre-op x-rays of adj and
opposing teeth, fill x-ray and
narrative of medical necessity
submitted with claim
0
18
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
D2957
Each Additional Prefabricated
Post - Same Tooth
Yes-Retro Review
0
18
1
60
MONTH
Teeth Covered:
1-3
14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 92 (SN)
AGP_KanCare
CHIP (0-18)
D3110
Pulp Cap - Direct (Excluding
Final Restoration)
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D3220
Therapeutic Pulpotomy
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
days of D3310-D3331 on
same tooth.
AGP_KanCare
CHIP (0-18)
D3221
Pulpal Debridement - Primary
And Permanent Teeth
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
same tooth.
AGP_KanCare
CHIP (0-18)
D3222
Partial Pulpotomy For
Apexogenesis - Permanent
Tooth
Yes-Retro Review
Pre-operative x-rays (excluding
bitewings), submitted with
claim.
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Should only be performed
as preparation for
endodontic treatment.
Teeth Covered:
1 - 32
51 - 82 (SN)
Product
AGP_KanCare
CHIP (0-18)
Code
D3310
Code Description
Endodontic Therapy, Anterior
Tooth (Excluding Final
Restoration)
AGP_KanCare
CHIP (0-18)
D3320
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
1
Period
Length
1
Period
Type
LIFETIME
PER
TOOTH
No
N/A
Age Min
0
ADDITIONAL NOTES
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
Endodontic Therapy, Bicuspid
Restoration)
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
D3330
Endodontic Therapy, Molar
(Excluding Final Restoration)
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D3331
Treatment Of Root Canal
Obstruction; Non-Surgical
Access
Yes-Retro Review
bitewings) and narrative of
medical necessity, submitted
with claim.
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D3351
Apexification / Recalcification /
Pulpal Regeneration - Initial
Visit
No
Pre- and postoperative
radiographs shall be
maintained in beneficiary
records
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D3352
Pulpal Regeneration - Interim
No
records
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
Product
AGP_KanCare
CHIP (0-18)
Code
D3353
Code Description
Pulpal Regeneration - Final
Visit
AGP_KanCare
CHIP (0-18)
D3410
Apicoectomy / Periradicular
Surgery - Anterior
AGP_KanCare
CHIP (0-18)
D3421
AGP_KanCare
CHIP (0-18)
Auth Required
BENEFIT DETAILS
Max
Count
Period
Length
Period
Type
Reqd Docs
records
Age Min
0
Age Max
18
No
records
0
18
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
Surgery - Bicuspid (First Root)
No
N/A
0
18
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
D3425
Surgery - Molar (First Root)
No
N/A
0
18
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D3426
Surgery - Each Additional
Root)
No
N/A
0
18
Teeth Covered:
1 - 5, 12 - 21
28 - 32
51 - 55 (SN)
62 - 71 (SN)
78 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D3430
Retrograde Filling - Per Root
No
records
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
No
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
BENEFIT DETAILS
Max
Count
Period
Length
Period
Type
Product
AGP_KanCare
CHIP (0-18)
Code
D4210
Code Description
Gingivectomy Or
Gingivoplasty - Four Or More
Contiguous Teeth
Auth Required
Yes-Retro Review
Reqd Docs
Pre-op x-rays, perio charting,
treatment plan and narrative of
with claim.
Age Min
0
Age Max
18
ADDITIONAL NOTES
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
A minimum of four
affected teeth in the
quadrant.
AGP_KanCare
CHIP (0-18)
D4211
Gingivectomy Or
Gingivoplasty - One To Three
Contiguous Teeth
Yes-Retro Review
with claim.
0
18
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
One to three affected
teeth in the quadrant.
AGP_KanCare
CHIP (0-18)
D4230
Anatomical Crown Exposure Four Or More Contiguous
Teeth Per Quadrant
Yes-Retro Review
and narrative of medical
necessity, photo (optional),
submitted with claim.
0
18
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Must be billed same date
same tooth in conjunction
with the restorative codes
(D2140 - D2957).
AGP_KanCare
CHIP (0-18)
D4231
Anatomical Crown Exposure One To Three Teeth Per
Quadrant
Yes-Retro Review
0
18
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Same date and same
tooth in conjunction with
the restorative code.
AGP_KanCare
CHIP (0-18)
D4268
Surgical Revision Procedure,
Per Tooth
Yes-Retro Review
Pre operative x-rays and
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
Only covered after
D4210.
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D4341
Code Description
Periodontal Scaling And Root
Planing - Four Or More Teeth
Per Quadrant
Auth Required
Yes-Retro Review
Reqd Docs
Periodontal charting and pre-op
x-rays, and treatment plan
There must be radiographic
evidence of root calculus or
noticeable loss of bone support.
Age Min
0
Age Max
18
Max
Count
4
Period
Length
12
Period
Type
MONTH
AGP_KanCare
CHIP (0-18)
D4342
Planing - One To Three Teeth
Per Quadrant
Yes-Retro Review
0
18
4
12
MONTH
AGP_KanCare
CHIP (0-18)
D4355
Full Mouth Debridement
No
Documentation of medical
necessity shall be maintained in
beneficiary records.
0
18
1
12
MONTH
AGP_KanCare
CHIP (0-18)
D5110
Complete Denture - Maxillary
Yes-Retro Review
Pre op x-rays, treatment plan
with claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5120
Complete Denture Mandibular
Yes-Retro Review
with claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5211
Maxillary Partial Denture Resin Base
Yes-Retro Review
opposing teeth, trmt plan with
claim
0
18
1
60
MONTH
ADDITIONAL NOTES
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
A minimum of four
quadrant.
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D5212
Code Description
Mandibular Partial Denture Resin Base
Auth Required
Yes-Retro Review
Reqd Docs
claim
Age Min
0
Age Max
18
Max
Count
1
Period
Length
60
Period
Type
MONTH
AGP_KanCare
CHIP (0-18)
D5213
Maxillary Partial Denture Cast Metal Framework With
Resin Denture Bases
Yes-Retro Review
claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5214
Mandibular Partial Denture Cast Metal Framework With
Resin Denture Bases
Yes-Retro Review
claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5225
Maxillary Partial Denture Flexible Base
Yes-Retro Review
claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5226
Mandibular Partial Denture Flexible Base
Yes-Retro Review
claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5281
Removable Unilateral Partial
Denture - One Piece Cast
Metal
Yes-Retro Review
claim
0
18
1
60
MONTH
AGP_KanCare
CHIP (0-18)
D5410
Adjust Complete Denture Maxillary
No
N/A
0
18
months of placement.
AGP_KanCare
CHIP (0-18)
D5411
Adjust Complete Denture Mandibular
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5421
Adjust Partial Denture Maxillary
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5422
Adjust Partial Denture Mandibular
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5510
Repair Broken Complete
Denture Base
No
N/A
0
18
Area covered:
01 (UA)
02 (LA)
AGP_KanCare
CHIP (0-18)
D5520
Replace Missing Or Broken
Teeth - Complete Denture
(Each Tooth)
No
N/A
0
18
Teeth Covered:
1 - 32
ADDITIONAL NOTES
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Product
AGP_KanCare
CHIP (0-18)
Code
D5610
Code Description
Repair Resin Denture Base
Auth Required
No
AGP_KanCare
CHIP (0-18)
D5620
Repair Cast Framework
AGP_KanCare
CHIP (0-18)
D5630
AGP_KanCare
CHIP (0-18)
Reqd Docs
BENEFIT DETAILS
Max
Count
Period
Length
Period
Type
N/A
Age Min
0
Age Max
18
No
N/A
0
18
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Repair Or Replace Broken
Clasp
No
N/A
0
18
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
D5640
Replace Broken Teeth - Per
Tooth
No
N/A
0
18
Teeth Covered:
1 - 32
AGP_KanCare
CHIP (0-18)
D5650
Add Tooth To Existing Partial
Denture
No
N/A
0
18
Teeth Covered:
1 - 32
AGP_KanCare
CHIP (0-18)
D5660
Add Clasp To Existing Partial
Denture
No
N/A
0
18
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
CHIP (0-18)
D5670
Replace All Teeth And Acrylic
On Cast Metal Framework
(Maxillary)
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5671
(Mandibular)
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5750
Reline Complete Maxillary
Denture (Laboratory)
No
N/A
0
18
1
24
MONTH
ADDITIONAL NOTES
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Product
AGP_KanCare
CHIP (0-18)
Code
D5751
Code Description
Reline Complete Mandibular
AGP_KanCare
CHIP (0-18)
D5760
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
1
Period
Length
24
Period
Type
MONTH
No
N/A
Age Min
0
ADDITIONAL NOTES
Reline Maxillary Partial
No
N/A
0
18
1
24
MONTH
D5761
Reline Mandibular Partial
No
N/A
0
18
1
24
MONTH
AGP_KanCare
CHIP (0-18)
D5850
Tissue Conditioning, Maxillary
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D5851
Tissue Conditioning,
Mandibular
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D6100
Implant Removal, By Report
Yes-Retro Review
Pre-op & post-op x-rays, narr of
med nec with claim
0
18
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
CHIP (0-18)
D6930
Recement Fixed Partial
Denture
No
N/A
0
18
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
CHIP (0-18)
D7140
Extraction, Erupted Tooth Or
Exposed Root
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
Removal of asymptomic
tooth not covered.
AGP_KanCare
CHIP (0-18)
D7210
Surgical Removal Or Erupted
Tooth
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
Includes cutting of gingiva
and bone, removal of
tooth structure, and
closure.
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D7220
Code Description
Removal Of Impacted Tooth Soft Tissue
Auth Required
Yes-Retro Review
Reqd Docs
Pre-op x-rays (excluding
bitewings) and narr of med nec
with claim
Age Min
0
Age Max
18
Max
Count
1
Period
Length
1
Period
Type
LIFETIME
PER
TOOTH
AGP_KanCare
CHIP (0-18)
D7230
Removal Of Impacted Tooth Partially Bony
Yes-Retro Review
with claim
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
AGP_KanCare
CHIP (0-18)
D7240
Removal Of Impacted Tooth Completely Bony
Yes-Retro Review
with claim
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
AGP_KanCare
CHIP (0-18)
D7241
Removal Of Impacted Tooth Completely Bony, Unusual
Surgical Complications
Yes-Retro Review
with claim
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
Unusual complications
such as nerve dissection,
separate closure of the
maxillary sinus, or
aberrant tooth position.
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
BENEFIT DETAILS
Age Min
0
Age Max
18
Max
Count
1
Period
Length
1
Period
Type
LIFETIME
PER
TOOTH
radiographs and narrative of
medical necessity submitted
with claim.
0
18
1
1
LIFETIME
PER
TOOTH
No
N/A
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
Includes splinting and/or
stabilization.
Surgical Access Of An
Unerupted Tooth
Yes-Retro Review
Pre-op x-rays, narr of med neck
with claim
0
18
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Will not be payable
unless the orthodontic
treatment has been
authorized as a covered
benefit.
D7285
Biopsy Of Oral Tissue - Hard
(Bone, Tooth)
No
Pathology report should be kept
in beneficiary record.
0
18
D7286
Biopsy Of Oral Tissue - Soft
No
0
18
Product
AGP_KanCare
CHIP (0-18)
Code
D7250
Code Description
Surgical Removal Of Residual
Tooth (Cutting Procedure)
Auth Required
Reqd Docs
No
N/A
AGP_KanCare
CHIP (0-18)
D7260
Oroantral Fistula Closure
Yes-Retro Review
AGP_KanCare
CHIP (0-18)
D7270
Reimplantation And/Or
Stabilization Of Accidentally
Evulsed / Displaced Tooth
AGP_KanCare
CHIP (0-18)
D7280
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
ADDITIONAL NOTES
Teeth Covered:
1 - 32
51 - 82 (SN)
A–T
AS - TS (SN)
closure.
Will not be paid to the
providers or group that
originally removed the
tooth.
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D7320
Code Description
Alveoloplasty Not In
Conjunction With Extractions Four Or More Teeth
Auth Required
Yes-Retro Review
Reqd Docs
Pre-op x-rays, narr of med nec
with claim
Age Min
0
Age Max
18
AGP_KanCare
CHIP (0-18)
D7350
Vesibuloplasty - Ridge
Extension (Including Soft
Tissue Grafts)
Yes-Retro Review
with claim
0
18
AGP_KanCare
CHIP (0-18)
D7410
Excision Of Benign Lesion Up
To 1.25 Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7411
Excision Of Benign Lesion
Greater Than 1.25 Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7412
Excision Of Benign Lesion,
Complicated
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7413
Excision Of Malignant Lesion
Up To 1.25 Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7414
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7415
Excision Of Malignant Lesion,
Complicated
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7440
Excision Of Malignant Tumor Lesion Diameter Up To 1.25
Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7441
Excision Of Malignant Tumor Lesion Diameter Greater Than
1.25 Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7450
Removal Of Benign
Odontogenic Cyst Or Tumor Dia Up To 1.25 Cm
No
N/A
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
No extractions performed
in an edentulous area.
Not covered when
day as an extraction for
the same tooth.
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Product
AGP_KanCare
CHIP (0-18)
Code
D7451
Code Description
Removal Of Benign
Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm
AGP_KanCare
CHIP (0-18)
D7460
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
Age Max
18
Max
Count
Period
Length
Period
Type
No
N/A
Age Min
0
ADDITIONAL NOTES
Removal Of Benign
Nonodontogenic Cyst Or
Tumor - Dia Up To 1.25 Cm
No
N/A
0
18
D7461
Removal Of Benign
Tumor - Dia Greater Than
1.25 Cm
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7471
Removal Of Lateral Exostosis
(Maxilla Or Mandible)
Yes-Retro Review
with claim
0
18
1
1
ONCE
PER
LIFETIME
AGP_KanCare
CHIP (0-18)
D7472
Removal Of Torus Palatinus
Yes-Retro Review
with claim
0
18
1
1
ONCE
PER
LIFETIME
AGP_KanCare
CHIP (0-18)
D7473
Removal Of Torus
Mandibularis
Yes-Retro Review
with claim
0
18
1
1
ONCE
PER
LIFETIME
AGP_KanCare
CHIP (0-18)
D7490
Radical Resection Of Maxilla
Or Mandible
Yes-Retro Review
with claim
0
18
Area Covered:
01 (UA)
02 (LA)
AGP_KanCare
CHIP (0-18)
D7510
Incision And Drainage Of
Abscess - Intraoral Soft Tissue
No
N/A
0
18
Not covered same date of
service as D7511
AGP_KanCare
CHIP (0-18)
D7511
- Complicated
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7520
Abscess - Extraoral Soft
Tissue
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7521
Tissue - Complicated
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7530
Removal Of Foreign Body
From Mucosa
No
N/A
0
18
Area Covered:
01 (UA)
02 (LA)
service as D7521.
Product
AGP_KanCare
CHIP (0-18)
Code
D7540
Code Description
Removal Of Reaction
Producing Foreign Bodies
AGP_KanCare
CHIP (0-18)
D7550
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
No
N/A
Age Min
0
Age Max
18
Partial
Ostectomy/Sequestrectomy
For Removal Of Non-Vital
Bone
No
N/A
0
18
D7560
Maxillary Sinusotomy For
Removal Of Tooth Fragment
Or Foreign Body
Yes-Retro Review
radiographs along with
must be submitted with claim.
0
18
AGP_KanCare
CHIP (0-18)
D7610
Maxilla - Open Reduction
(Teeth Immobilized, If Present)
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7620
Maxilla - Closed Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7630
Mandible - Open Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7640
Mandible - Closed Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7650
Malar And/Or Zygomatic Arch
- Open Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7660
- Closed Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7670
Alveolus - Closed Reduction,
May Include Stabilization Of
Teeth
No
N/A
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
Teeth Covered:
1 - 32
May include stabilization.
Product
AGP_KanCare
CHIP (0-18)
Code
D7680
Code Description
Facial Bones - Complicated
Reduction With Fixation And
Multiple Surgical
Auth Required
Yes-Retro Review
Reqd Docs
AGP_KanCare
CHIP (0-18)
D7710
No
AGP_KanCare
CHIP (0-18)
D7720
AGP_KanCare
CHIP (0-18)
D7730
AGP_KanCare
CHIP (0-18)
BENEFIT DETAILS
Age Min
0
Age Max
18
N/A
0
18
No
N/A
0
18
No
Postoperative radiographs must
be available in the beneficiary
records.
0
18
D7740
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7750
- Open Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7760
- Closed Reduction
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7770
Alveolus - Open Reduction
Stabilization Of Teeth
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7780
Multiple Surgical
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7820
Closed Reduction Of
Dislocation
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7860
Arthrotomy
Yes-Retro Review
med nec with claim
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
Product
AGP_KanCare
CHIP (0-18)
Code
D7865
Code Description
Arthroplasty
Auth Required
Yes-Retro Review
Reqd Docs
AGP_KanCare
CHIP (0-18)
D7910
Suture Of Recent Small
Wounds Up To 5 Cm
No
AGP_KanCare
CHIP (0-18)
D7911
Complicated Suture - Up To 5
Cm
AGP_KanCare
CHIP (0-18)
D7912
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
BENEFIT DETAILS
Age Min
0
Age Max
18
N/A
0
18
No
N/A
0
18
Complicated Suture - Greater
Than 5 Cm
No
N/A
0
18
D7920
Skin Graft (Identify Defect
Covered, Location And Type
Of Graft)
Yes-Retro Review
med nec with claim
0
18
D7955
Repair Of Maxillofacial Soft
And/Or Hard Tissue Defect
Yes-Retro Review
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
Not covered on dame day
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Product
AGP_KanCare
CHIP (0-18)
Code
D7960
Code Description
Frenulectomy - Also Known As
Frenectomy Or Frenotomy Separate Procedure
AGP_KanCare
CHIP (0-18)
D7963
AGP_KanCare
CHIP (0-18)
Auth Required
Reqd Docs
BENEFIT DETAILS
No
N/A
Age Min
0
Age Max
18
Frenuloplasty
No
N/A
0
18
D7971
Excision Of Pericoronal
Gingiva
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7980
Sialolithotomy
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7981
Excision Of Salivary Gland, By
Report
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7982
Sialodochoplasty
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D7983
Closure Of Salivary Fistula
Yes-Retro Review
Narrative of medical necessity
with claim, x-rays or photos
optional, submitted with claim.
0
18
AGP_KanCare
CHIP (0-18)
D7990
Emergency Tracheotomy
No
N/A
0
18
AGP_KanCare
CHIP (0-18)
D8010
Limited Orthodontic Treatment
Of The Primary Dentition
Yes-Prior Authorization
Pan and/or cephalometric xray, diag quality photos, narr of
med nec / trm plan
0
18
Max
Count
1
Period
Length
1
Period
Type
LIFETIME
ADDITIONAL NOTES
Area Covered:
01 (UA)
02 (LA)
ONCE PER LIFETIME.
Per location.
Lingual, Buccal or Labial.
service as D7963. The
frenum may be excised
when the tongue has
limited mobility; for large
diastemas between teeth,
or when the frenum
interferes with a
prosthetic appliance; or
when it is the etiology of
periodontal tissue
disease.
Excision of frenum with
the excision or
repositioning of abervant
muscle and z-plasty or
other local flap closure.
Teeth Covered:
1 - 32
Limited to one
replacement. Limited
orthodontic treatment
requires prior
authorization and is only
covered for eligible
children with documented
medical necessity.
BENEFIT DETAILS
Max
Count
Period
Length
Period
Type
Product
AGP_KanCare
CHIP (0-18)
Code
D8020
Code Description
Of The Transitional Dentition
Auth Required
Reqd Docs
med nec / trm plan
Age Min
0
Age Max
18
ADDITIONAL NOTES
Limited to one
requires prior
medical necessity.
AGP_KanCare
CHIP (0-18)
D8050
Interceptive Orthodontic
Treatment Of The Primary
Dentition
med nec / trm plan
0
18
Interceptive orthodontic
treatment requires prior
medical necessity.
AGP_KanCare
CHIP (0-18)
D8060
Treatment Of The Transitional
Dentition
med nec / trm plan
0
18
medical necessity.
AGP_KanCare
CHIP (0-18)
D8070
Comprehensive Orthodontic
Dentition
med nec / trm plan
0
18
Comprehensive
requires prior
medical necessity.
AGP_KanCare
CHIP (0-18)
D8080
Treatment Of The Adolescent
Dentition
med nec / trm plan
0
18
Comprehensive
requires prior
medical necessity.
AGP_KanCare
CHIP (0-18)
D8210
Removable Appliance Therapy
med nec / trm plan
0
18
Limited to one
replacement. Removable
appliance therapy
requires prior
medical necessity.
AGP_KanCare
CHIP (0-18)
D8220
Fixed Appliance Therapy
med nec / trm plan
0
18
Limited to one
appliance therapy
requires prior
medical necessity.
BENEFIT DETAILS
Product
AGP_KanCare
CHIP (0-18)
Code
D8999
Code Description
Unspecified Orthodontic
Procedure, By Report
Auth Required
Reqd Docs
Description of procedure and
Age Min
0
Age Max
18
AGP_KanCare
CHIP (0-18)
D9212
Trigeminal Division Block
Anesthesia
No
shall be maintained in
0
18
AGP_KanCare
CHIP (0-18)
D9220
Deep Sedation/General
Anesthesia - First 30 Minutes
Yes-Retro Review
and treatment plan with claim
0
18
AGP_KanCare
CHIP (0-18)
D9221
Anesthesia - Each Additional
15 Minutes
Yes-Retro Review
0
18
AGP_KanCare
CHIP (0-18)
D9230
Inhalation Of
Nitrous/Analgesia, Anxiolysis
No
0
18
AGP_KanCare
CHIP (0-18)
D9241
Intravenous Conscious
Sedation/Analgesia - First 30
Minutes
Yes-Retro Review
0
18
AGP_KanCare
CHIP (0-18)
D9242
Sedation/Analgesia - Each
Additional 15 Minutes
Yes-Retro Review
0
18
Max
Count
Period
Length
Period
Type
ADDITIONAL NOTES
All orthodontic treatment
requires prior
medical necessity.
D9220 and D9221 are
only billable when dental
services other then ONLY
diagnostic are provided
on the same date of
service.
D9220 and D9221 are
on the same date of
service.
Not covered when billed
with only diagnostic
and/or preventative
services (D0120 through
D1208, D1515 through
D1550, D9410, D9420).
Product
AGP_KanCare
CHIP (0-18)
Code
D9310
Code Description
Consultation - Diagnostic
Service Provided By Dentist
Or Physician
Auth Required
AGP_KanCare
CHIP (0-18)
D9410
House/Extended Care Facility
Call
No
AGP_KanCare
CHIP (0-18)
D9420
Hospital Or Ambulatory
Surgical Center Call
AGP_KanCare
CHIP (0-18)
D9610
AGP_KanCare
CHIP (0-18)
AGP_KanCare
CHIP (0-18)
Max
Count
1
Period
Length
12
Period
Type
MONTH
Age Min
0
Age Max
18
0
18
Extended Care Facilities
only.
No
0
18
Hospital Facilities only.
Therapeutic Parenteral Drug,
Single Administration
No
Description and dosage of drug
0
18
D9920
Behavior Management, By
Report
Yes-Retro Review
with claim
0
18
D9999
Unspecified Adjunctive
Yes-Retro Review
narrative of medical necessity,
0
18
No
Reqd Docs
Narrative of the consultation for
dental services shall be
records.
BENEFIT DETAILS
ADDITIONAL NOTES
D9310 is billable when
ONLY diagnostic services
are provided on the same
date of service.
One per 12 months by
same provider.
One inpatient follow up
per beneficiary within a
10 day period by same
provider.
Not covered on the same
date of service as D0120D0170, D9410, D9420.
Effective with dates of
service on and after July
1, 2011, registered dental
hygienists with an
extended care permit
can bill for D9999 clinical and caries risk
assessment, toothbrush
prophylaxis of a child 0-3
years of age
and counseling to
parents/primary
caregivers.
AGP_KanCare Medicaid - Title 19 Adult ( over 21) and Title 19 Child (0-20) - Please note age limitations
****Codes with an Age Max 999 are covered for both children and adults and codes with an Age Max of 20 are covered for children only.****
Title 19 Adult Ages 21 and Over - Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral
pathology, and develop an adequate treatment plan for the beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with
or to determine if extractions are medically necessary.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0120
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0140
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0145
Oral Evaluation, Patient Under
Three
No
N/A
0
2
Max
Count
1
Period
Length
Period
Type
6
MONTH
D0140, D0145, D0150,
D0170) per date of
months)
D0140, D0145, D0150,
D0170) per date of
billing group. Limited oral
when performed in
conjunction with
treatment to address an
emergency situation. An
emergency is defined as
treatment medically
necessary to treat pain,
infection, swelling,
uncontrolled bleeding, or
traumatic injury. (D0140
is not limited to 1x every
6 months)
1
6
MONTH
D0140, D0145, D0150,
D0170) per date of
months)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
0
999
1
6
MONTH
One comprehensive
exam per beneficiary, per
one exam (D0120,
D0145, or D0150) every
six months per
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0170
Problem Focused
No
N/A
0
999
1
12
MONTH
One per 12 months.
previously existing
radiographs.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0210
No
N/A
0
999
1
36
MONTH
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0220
Intraoral - Periapical First Film
No
N/A
0
999
1
1
DAYS
One per day. Any
reimbursed.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0230
Additional Film
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0240
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0250
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0260
Film
No
N/A
0
999
Max
Count
Period
Length
Period
Type
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0270
No
N/A
0
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0272
No
N/A
0
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0273
No
N/A
0
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0274
No
N/A
0
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0277
Films
No
N/A
0
20
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
of service, per
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0290
Posterior - Anterior Or Lateral
Skull And Facial Bone Survey
Film
No
N/A
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0321
No
N/A
0
20
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0322
Tomographic Survey
No
N/A
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0330
Panoramic Film
No
N/A
0
999
1
36
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D0460
Pulp Vitality Tests
No
N/A
0
20
3
1
DAYS
D1110
Prophylaxis - Adult
No
N/A
13
999
1
6
MONTH
D1120
Prophylaxis - Child
No
N/A
0
12
1
6
MONTH
D1206
Topical Fluoride Varnish
No
N/A
0
20
3
12
MONTH
D1208
Topical Application Of Fluoride
No
N/A
0
20
3
12
MONTH
MONTH
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
are:
1 - 32, 51 - 82 (SN), A T, AS - TS (SN)
One per six months.
One per six months.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D1351
Sealant - Per Tooth
No
N/A
0
20
1
12
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D1510
Space Maintainer - Fixed Unilateral
No
N/A
0
20
1
12
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D1515
Space Maintainer - Fixed Bilateral
No
N/A
0
20
1
12
MONTH
D1525
Space Maintainer - Removable
- Bilateral
No
N/A
0
20
1
12
MONTH
D1550
Re-Cementation Of Space
Maintainer
No
N/A
0
20
Sealants are
reimbursable when
placed on the occlusal or
occlusal-buccal surfaces
of lower 1st and 2nd
permanent molars or
upper 1st and 2nd
permanent molars as well
as permanent upper and
lower bicuspids. Teeth
must be caries free.
Sealant is not covered
when placed over
restorations.
1 per 12 months per
quadrant.
10 (UR)
20 (UL)
30 (LL)
40 (LR)
01 (UA)
02 (LA)
01 (UA)
02 (LA)
months of initial
placement within
quadrant or arch.
10 (UR)
20 (UL)
30 (LL)
40 (LR)
01 (UA)
02 (LA)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2140
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
D2150
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
D2160
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
D2161
Permanent
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
D2330
Surface, Anterior
No
N/A
0
20
1
12
MONTH
D2331
Surfaces, Anterior
No
N/A
0
20
1
12
MONTH
D2332
No
N/A
0
20
1
12
MONTH
D2335
Resin-Based Composite - Four
Or More Surfaces Or Involving
Incisal Angle
No
N/A
0
20
1
12
MONTH
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2390
Crown, Anterior
No
N/A
0
20
1
12
MONTH
D2391
Surface, Posterior
No
N/A
0
20
1
12
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2392
Surfaces, Posterior
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2393
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2394
Resin-Based Composite - Four
Or More Surfaces, Posterior
No
N/A
0
20
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
- RS (SN)
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51
- 55 (SN), 62 - 71 (SN),
78 - 82 (SN,) A, B, I - L,
(SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2710
Crown - Resin-Based
Yes-Retro Review for
beneficiaries aged 0-20
adjacent and opposing teeth. If a
tooth has had RCT, a
also required showing the entire
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
Not a covered benefit for
Beneficiaries aged 21
and older.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2740
Substrate
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2751
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2752
Noble Metal
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2783
Crown - 3/4 Porcelain/Ceramic
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2791
Crown - Full Cast
tooth, with claim
0
20
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2792
Crown - Full Cast Noble Metal
tooth, with claim
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2910
Partial Coverage Restoration
No
N/A
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
D2920
Recement Crown
No
N/A
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
D2930
No
N/A
0
20
1
24
MONTH
Teeth Covered:
A-T
AS - TS (SN)
period.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2931
Crown - Permanent Tooth
No
N/A
0
20
1
24
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
1
Period
Length
60
Period
Type
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2934
Prefabricated Esthetic Coated
Stainless Steel Crown Primary Tooth
No
N/A
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2940
No
N/A
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
or liner under a
restoration.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2951
Pin Retention - Per Tooth, In
Addition To Restoration
No
N/A
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
D2954
Prefabricated Post And Core
In Addition To Crown
Yes-Retro Review
0
20
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D2957
Each Additional Prefabricated
Post - Same Tooth
0
20
1
60
MONTH
Teeth Covered:
1-3
14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 92 (SN)
1
Period
Length
24
Period
Type
MONTH
Teeth Covered:
C - H, M -R
CS - HS (SN)
MS - RS (SN)
period.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3110
Pulp Cap - Direct (Excluding
Final Restoration)
No
N/A
0
20
D3220
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
same tooth.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3221
Pulpal Debridement - Primary
And Permanent Teeth
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
same tooth.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3222
Tooth
Yes-Retro Review
bitewings)
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
as preparation for
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3310
Endodontic Therapy, Anterior
Restoration)
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3320
Endodontic Therapy, Bicuspid
Restoration)
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3330
(Excluding Final Restoration)
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3331
Access
with claim.
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3351
Pulpal Regeneration - Initial
Visit
No
radiographs shall be maintained
in beneficiary records
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3352
Pulpal Regeneration - Interim
No
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3353
Pulpal Regeneration - Final
Visit
No
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3410
Surgery - Anterior
No
0
20
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3421
Surgery - Bicuspid (First Root)
No
N/A
0
20
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3425
No
N/A
0
20
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3426
Root)
No
N/A
0
20
Teeth Covered:
1 - 5, 12 - 21
28 - 32
51 - 55 (SN)
62 - 71 (SN)
78 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D3430
Retrograde Filling - Per Root
No
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4210
Gingivectomy Or Gingivoplasty
- Four Or More Contiguous
Teeth
Yes-Retro Review
with claim.
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
A minimum of four
quadrant.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4211
Gingivectomy Or Gingivoplasty
- One To Three Contiguous
Teeth
Yes-Retro Review
with claim.
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4230
Anatomical Crown Exposure Four Or More Contiguous
Teeth Per Quadrant
Yes-Retro Review
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4231
Anatomical Crown Exposure One To Three Teeth Per
Quadrant
Yes-Retro Review
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Same date and same
tooth in conjunction with
the restorative code.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4268
Surgical Revision Procedure,
Per Tooth
Yes-Retro Review
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
Only covered after
D4210.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4341
Planing - Four Or More Teeth
Per Quadrant
Yes-Retro Review
0
20
4
12
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
A minimum of four
quadrant.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4342
Planing - One To Three Teeth
Per Quadrant
Yes-Retro Review
0
20
4
12
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D4355
No
0
20
1
12
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5110
Complete Denture - Maxillary
Yes-Retro Review
with claim
0
20
1
60
MONTH
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5120
Yes-Retro Review
with claim
0
20
1
60
MONTH
D5211
Yes-Retro Review
claim
0
20
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5212
Mandibular Partial Denture Resin Base
Yes-Retro Review
claim
0
20
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5213
Maxillary Partial Denture - Cast
Metal Framework With Resin
Denture Bases
Yes-Retro Review
claim
0
20
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5214
Mandibular Partial Denture Cast Metal Framework With
Resin Denture Bases
Yes-Retro Review
claim
0
20
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5225
Yes-Retro Review
claim
0
20
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5226
Mandibular Partial Denture Flexible Base
Yes-Retro Review
claim
0
20
1
60
MONTH
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5281
Removable Unilateral Partial
Denture - One Piece Cast
Metal
Yes-Retro Review
claim
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5410
No
N/A
0
20
D5411
No
N/A
0
20
D5421
No
N/A
0
20
D5422
No
N/A
0
20
D5510
Denture Base
No
N/A
0
20
Area covered:
01 (UA)
02 (LA)
D5520
Replace Missing Or Broken
Teeth - Complete Denture
(Each Tooth)
No
N/A
0
20
Teeth Covered:
1 - 32
D5610
Repair Resin Denture Base
No
N/A
0
20
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
1
Period
Length
60
Period
Type
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5620
No
N/A
0
20
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5630
Clasp
No
N/A
0
20
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5640
Replace Broken Teeth - Per
Tooth
No
N/A
0
20
Teeth Covered:
1 - 32
D5650
Add Tooth To Existing Partial
Denture
No
N/A
0
20
Teeth Covered:
1 - 32
D5660
Add Clasp To Existing Partial
Denture
No
N/A
0
20
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5670
(Maxillary)
No
N/A
0
20
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D5671
(Mandibular)
No
N/A
0
20
D5750
No
N/A
0
20
1
24
MONTH
D5751
Reline Complete Mandibular
No
N/A
0
20
1
24
MONTH
D5760
No
N/A
0
20
1
24
MONTH
D5761
No
N/A
0
20
1
24
MONTH
D5850
Tissue Conditioning, Maxillary
No
N/A
0
20
D5851
Mandibular
No
N/A
0
20
D6100
Implant Removal, By Report
Yes-Retro Review
med nec with claim
0
20
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D6930
Denture
No
N/A
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7140
Extraction, Erupted Tooth Or
Exposed Root
No
N/A
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7210
Surgical Removal Or Erupted
Tooth
No
N/A
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
closure.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7220
Removal Of Impacted Tooth Soft Tissue
Yes-Retro Review
with claim
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7230
Removal Of Impacted Tooth Partially Bony
Yes-Retro Review
with claim
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7240
Removal Of Impacted Tooth Completely Bony
Yes-Retro Review
with claim
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7241
Removal Of Impacted Tooth Completely Bony, Unusual
Surgical Complications
Yes-Retro Review
with claim
0
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
closure.
maxillary sinus, or
aberrant tooth position.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7250
Surgical Removal Of Residual
Tooth (Cutting Procedure)
No
Preoperative radiographs and
0
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7260
Yes-Retro Review
medical necessity submitted with
claim.
0
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7270
Stabilization Of Accidentally
Evulsed / Displaced Tooth
No
N/A
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
stabilization.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7280
Unerupted Tooth
Yes-Retro Review
with claim
0
20
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Will not be payable
unless the orthodontic
treatment has been
authorized as a covered
benefit.
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
closure. Will not be paid
to the providers or group
that originally removed
the tooth.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7285
Biopsy Of Oral Tissue - Hard
(Bone, Tooth)
No
0
999
D7286
Biopsy Of Oral Tissue - Soft
No
0
999
D7320
Conjunction With Extractions Four Or More Teeth
Yes-Retro Review
with claim
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in an edentulous area.
Not covered when
day as an extraction for
the same tooth.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7350
Tissue Grafts)
Yes-Retro Review
with claim
0
20
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7410
Excision Of Benign Lesion Up
To 1.25 Cm
No
N/A
0
999
D7411
No
N/A
0
999
1
1
DAYS
D7412
Complicated
No
N/A
0
999
1
1
DAYS
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7413
Up To 1.25 Cm
No
N/A
0
999
D7414
No
N/A
0
999
D7415
Excision Of Malignant Lesion,
Complicated
No
N/A
0
999
D7440
Excision Of Malignant Tumor Lesion Diameter Up To 1.25
Cm
No
N/A
0
999
D7441
Excision Of Malignant Tumor Lesion Diameter Greater Than
1.25 Cm
No
N/A
0
999
D7450
Removal Of Benign
Odontogenic Cyst Or Tumor Dia Up To 1.25 Cm
No
N/A
0
999
D7451
Removal Of Benign
Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm
No
N/A
0
999
D7460
Removal Of Benign
Tumor - Dia Up To 1.25 Cm
No
N/A
0
999
Max
Count
Period
Length
Period
Type
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7461
Removal Of Benign
1.25 Cm
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7471
Removal Of Lateral Exostosis
(Maxilla Or Mandible)
Yes-Retro Review
with claim
0
999
1
1
ONCE
PER
LIFETIME
D7472
Removal Of Torus Palatinus
Yes-Retro Review
with claim
0
999
1
1
ONCE
PER
LIFETIME
D7473
Removal Of Torus
Mandibularis
Yes-Retro Review
with claim
0
999
1
1
ONCE
PER
LIFETIME
D7490
Radical Resection Of Maxilla
Or Mandible
Yes-Retro Review
with claim
0
999
Area Covered:
01 (UA)
02 (LA)
D7510
No
N/A
0
999
service as D7511
D7511
- Complicated
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7520
Tissue
No
N/A
0
999
Area Covered:
01 (UA)
02 (LA)
service as D7521.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7521
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7530
From Mucosa
No
N/A
0
999
D7540
Removal Of Reaction
No
N/A
0
999
D7550
Partial
Bone
No
N/A
0
999
D7560
Removal Of Tooth Fragment
Or Foreign Body
Yes-Retro Review
radiographs along with narrative
of medical necessity must be
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7610
No
N/A
0
999
D7620
No
N/A
0
999
Max
Count
Period
Length
Period
Type
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7630
No
N/A
0
999
D7640
No
N/A
0
999
D7650
Malar And/Or Zygomatic Arch Open Reduction
No
N/A
0
999
D7660
Malar And/Or Zygomatic Arch Closed Reduction
No
N/A
0
999
D7670
Alveolus - Closed Reduction,
May Include Stabilization Of
Teeth
No
N/A
0
999
D7680
Multiple Surgical
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
D7710
No
N/A
0
999
D7720
No
N/A
0
999
Max
Count
Period
Length
Period
Type
Teeth Covered:
1 - 32
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7730
No
records.
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7740
No
N/A
0
999
D7750
Malar And/Or Zygomatic Arch Open Reduction
No
N/A
0
999
D7760
Malar And/Or Zygomatic Arch Closed Reduction
No
N/A
0
999
D7770
No
N/A
0
999
D7780
Multiple Surgical
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7820
Closed Reduction Of
Dislocation
No
N/A
0
999
Medicaid Child
(0-20)
Max
Count
Period
Length
Period
Type
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7860
Arthrotomy
Yes-Retro Review
med nec with claim
0
999
D7865
Arthroplasty
Yes-Retro Review
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7910
Wounds Up To 5 Cm
No
N/A
0
999
as D7140, D7210,
D7220, D7230, D7240,
D7241, or D7250.
D7911
Complicated Suture - Up To 5
Cm
No
N/A
0
999
as D7140, D7210,
D7220, D7230, D7240,
D7241, or D7250.
D7912
Complicated Suture - Greater
Than 5 Cm
No
N/A
0
999
as D7140, D7210,
D7220, D7230, D7240,
D7241, or D7250.
D7920
Covered, Location And Type
Of Graft)
Yes-Retro Review
med nec with claim
0
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7955
Yes-Retro Review
0
20
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7960
Frenulectomy - Also Known As
Frenectomy Or Frenotomy Separate Procedure
No
N/A
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7963
Frenuloplasty
No
N/A
0
999
D7971
Gingiva
No
N/A
0
999
D7980
Sialolithotomy
No
N/A
0
999
Max
Count
1
Period
Length
Period
Type
1
LIFETIME
Area Covered:
01 (UA)
02 (LA)
when the tongue has
or when the frenum
interferes with a
prosthetic appliance; or
when it is the etiology of
periodontal tissue
disease.
the excision or
repositioning of abervant
muscle and z-plasty or
other local flap closure.
Teeth Covered:
1 - 32
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7981
Excision Of Salivary Gland, By
Report
No
N/A
0
999
D7982
Sialodochoplasty
No
N/A
0
999
D7983
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D7990
No
N/A
0
999
D8010
Of The Primary Dentition
Pan and/or cephalometric x-ray,
diag quality photos, narr of med
nec / trm plan
0
20
Limited to one
requires prior
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8020
Of The Transitional Dentition
nec / trm plan
0
20
Limited to one
requires prior
medical necessity.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8050
Treatment Of The Primary
Dentition
nec / trm plan
0
20
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8060
Dentition
nec / trm plan
0
20
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8070
Dentition
nec / trm plan
0
20
Comprehensive
requires prior
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8080
Treatment Of The Adolescent
Dentition
nec / trm plan
0
20
Comprehensive
requires prior
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8210
Removable Appliance Therapy
nec / trm plan
0
20
Limited to one
appliance therapy
requires prior
medical necessity.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8220
Fixed Appliance Therapy
nec / trm plan
0
20
Limited to one
appliance therapy
requires prior
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D8999
Unspecified Orthodontic
0
20
All orthodontic treatment
requires prior
medical necessity.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9212
Anesthesia
beneficiaries aged 21 999
with claim
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9220
Anesthesia - First 30 Minutes
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9221
Anesthesia - Each Additional
15 Minutes
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9230
Inhalation Of
Nitrous/Analgesia, Anxiolysis
No
0
999
For Beneficiary under age
21 a description and
dosage of drug shall be
maintained in the
beneficiaries records, no
Retro Review required.
D9220 and D9221 are
on the same date of
service.
D9220 and D9221 are
on the same date of
service.
with only diagnostic
and/or preventative
services (D0120 through
D1208, D1515 through
D1550, D9410, D9420).
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9241
Sedation/Analgesia - First 30
Minutes
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9242
Yes-Retro Review
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9310
Service Provided By Dentist Or
Physician
No
records.
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9410
House/Extended Care Facility
Call
No
0
999
only.
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9420
No
0
999
1
Period
Length
12
Period
Type
MONTH
date of service.
same provider.
One inpatient follow up
per beneficiary within a
10 day period by same
provider.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9610
Therapeutic Parenteral Drug,
Single Administration
beneficiaries aged 21 999
and description and dosage of
drug submitted with claim.
0
999
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9920
Report
Yes-Retro Review
with claim
0
20
D9972
External Bleaching - Per Arch
Endo fill x-ray, narrative of
medical necessity, photo
optional
21
999
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9973
External Bleaching - Per Tooth
optional
21
999
1
60
MONTH
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9974
Internal Bleaching - Per Tooth
optional
21
999
1
60
MONTH
For Beneficiary under age
21, a narrative of medical
necessity shall be
records, no Retro Review
required.
AUTHORIZATION
BENEFIT
ADDITIONAL
REQUIREMENTS
DETAILS
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
AGP_KanCare
Title 19
Medicaid Adult /
Medicaid Child
(0-20)
D9999
Yes-Retro Review
Age
Min
Age Max
0
20
Max
Count
Period
Length
Period
Type
Effective with dates of
service on and after July
1, 2011, registered dental
hygienists with an
extended care permit
can bill for D9999 clinical and caries risk
assessment, toothbrush
prophylaxis of a child 0-3
years of age
and counseling to
parents/primary
caregivers.
AGP_KanCare ICF_MR Adult Please note age limitations
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
ICF_MR Adult
D0120
Periodic Oral Evaluation Established patient
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0140
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
21
999
1
6
MONTH
One comprehensive exam
per beneficiary, per
one exam (D0120, D0145,
or D0150) every six
months per beneficiary, per
group.
AGP_KanCare
ICF_MR Adult
D0170
Problem Focused
No
N/A
21
999
1
12
MONTH
One per 12 months.
previously existing
radiographs.
1
Period
Length
Period
Type
6
MONTH
provider billing group. Only
one exam (D0120, D0140,
D0145, D0150, D0170) per
date of service, per
beneficiary, per provider or
every 6 months)
D0140, D0145, D0150,
D0170) per date of service,
group. Limited oral
when performed in
conjunction with treatment
to address an emergency
situation. An emergency is
defined as treatment
medically necessary to
treat pain, infection,
swelling, uncontrolled
bleeding, or traumatic
injury. (D0140 is not
limited to 1x every 6
months)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D0210
No
N/A
21
999
1
36
AGP_KanCare
ICF_MR Adult
D0220
Intraoral - Periapical First
Film
No
N/A
21
999
1
1
AGP_KanCare
ICF_MR Adult
D0230
Additional Film
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0240
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0250
No
N/A
21
999
MONTH
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
DAYS
One per day. Any
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
ICF_MR Adult
D0260
Film
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0270
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0272
No
N/A
21
999
Max
Count
Period
Length
Period
Type
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
D0274, D0277) per date of
billing group.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D0273
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
ICF_MR Adult
D0274
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
ICF_MR Adult
D0277
Films
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D0290
Posterior - Anterior Or
Lateral Skull And Facial
Bone Survey Film
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D0330
Panoramic Film
No
N/A
21
999
1
36
AGP_KanCare
ICF_MR Adult
D0460
Pulp Vitality Tests
No
N/A
21
999
3
1
DAYS
AGP_KanCare
ICF_MR Adult
D1110
Prophylaxis - Adult
No
N/A
21
999
1
6
MONTH
AGP_KanCare
ICF_MR Adult
D2140
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2150
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
ICF_MR Adult
D2160
Amalgam - Three
Permanent
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
ICF_MR Adult
D2161
Permanent
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
ICF_MR Adult
D2330
Resin-Based Composite One Surface, Anterior
No
N/A
21
999
1
12
MONTH
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
M - R, CS - HS (SN), MS RS (SN)
MONTH
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
are:
1 - 32, 51 - 82 (SN)
A-T
AS - TS (SN)
One per six months.
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D2331
Resin-Based Composite Two Surfaces, Anterior
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2332
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2335
anterior Or Involving Incisal
Angle
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2390
Crown, Anterior
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2391
Resin-Based Composite One Surface, Posterior
No
N/A
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D2392
Resin-Based Composite Two Surfaces, Posterior
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AS (SN), BS (SN), IS - LS
(SN), SS (SN),TS (SN)
AGP_KanCare
ICF_MR Adult
D2393
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
ICF_MR Adult
D2394
Posterior
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D2710
Crown - Resin-Based
No
tooth, with claim.
21
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
ICF_MR Adult
D2740
Substrate
No
tooth, with claim
21
999
1
60
MONTH
Teeth Covered: 6-11, 2227, 56-61(SN) 72-77(SN)
AGP_KanCare
ICF_MR Adult
D2751
Crown - Porcelain Fused
To Predominantly Base
Metal
No
tooth, with claim
21
999
1
60
MONTH
Teeth Covered: 1-32, 5182(SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D2752
To Noble Metal
No
tooth, with claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D2783
Crown - 3/4
Porcelain/Ceramic
No
tooth, with claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D2791
Crown - Full Cast
No
tooth, with claim
21
999
1
60
MONTH
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
ICF_MR Adult
D2792
Crown - Full Cast Noble
Metal
No
tooth, with claim
21
999
AGP_KanCare
ICF_MR Adult
D2910
Partial Coverage
Restoration
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D2920
Recement Crown
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D2930
Prefabricated Stainless
Steel Crown - Primary
Tooth
No
N/A
21
999
1
24
MONTH
Teeth Covered: A - T, AS TS (SN)
AGP_KanCare
ICF_MR Adult
D2931
Steel Crown - Permanent
Tooth
No
N/A
21
999
1
24
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
ICF_MR Adult
D2934
Prefabricated Esthetic
Coated Stainless Steel
No
N/A
21
20
1
24
MONTH
Teeth Covered:
C - H, M -R
CS - HS (SN)
MS - RS (SN)
period.
AGP_KanCare
ICF_MR Adult
D2940
Sedative Filling
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D2951
Pin Retention - Per Tooth,
In Addition To Restoration
No
N/A
21
999
1
Period
Length
60
Period
Type
MONTH
Templorary restoration
or liner under a restoration.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D2954
Prefabricated Post And
Core In Addition To Crown
Yes-Retro Review
opposing teeth, fill x-ray with
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D2957
Each Additional
Prefabricated Post - Same
Tooth
No
21
999
1
60
MONTH
Teeth Covered: 1-3, 14-19,
30-32, 51-53(SN), 6469(SN), 80-82(SN)
AGP_KanCare
ICF_MR Adult
D3110
Pulp Cap - Direct
(Excluding Final
Restoration)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D3220
(excluding final restoration)
- removal of pulp coronal to
the dentinocemental
junction and application of
medicament
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
Not covered within 30 days
of D3310-D3331 on same
tooth.
AGP_KanCare
ICF_MR Adult
D3221
Pulpal Debridement Primary And Permanent
Teeth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
ICF_MR Adult
D3222
Tooth with incomplete root
development
Yes-Retro Review
bitewings) submitted with claim.
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered: 1-32, 5182(SN), A -T, AS - TS(SN).
of D3310 - D3331 on same
tooth.
Teeth Covered: 1-32, 5182(SN). Should only be
performed as preparation
for endodontic treatment.
AGP_KanCare
ICF_MR Adult
D3310
Endodontic Therapy,
Anterior Tooth (Excluding
Final Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D3320
Endodontic Therapy,
Bicuspid Tooth (Excluding
Final Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
ICF_MR Adult
D3330
(Excluding Final
Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
ICF_MR Adult
D3331
Access
No
with claim.
21
999
AGP_KanCare
ICF_MR Adult
D3351
Apexification /
Recalcification / Pulpal
Regeneration - Initial Visit
No
21
999
AGP_KanCare
ICF_MR Adult
D3352
Apexification /
Regeneration - Interim
No
21
999
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D3353
Apexification /
Regeneration - Final Visit
No
21
999
AGP_KanCare
ICF_MR Adult
D3410
Apicoectomy /
Periradicular Surgery Anterior
No
21
999
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
ICF_MR Adult
D3421
Apicoectomy /
Periradicular Surgery Bicuspid (First Root)
No
N/A
21
999
Teeth Covered: 4, 5, 12,
13, 20, 21, 28, 29, 54(SN),
55(SN), 62(SN), 63(SN),
70(SN), 71(SN), 78(SN),
79(SN)
AGP_KanCare
ICF_MR Adult
D3425
Apicoectomy /
Periradicular Surgery Molar (First Root)
No
N/A
21
999
30-32, 51-53(SN), 6469(SN), 80-82(SN)
AGP_KanCare
ICF_MR Adult
D3426
Apicoectomy /
Periradicular Surgery Each Additional Root)
No
N/A
21
999
28-32, 51-55(SN), 6271(SN), 78-82(SN)
AGP_KanCare
ICF_MR Adult
D3430
Retrograde Filling - Per
Root
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
ICF_MR Adult
D4210
Gingivectomy Or
Gingivoplasty - Four Or
More Contiguous Teeth
No
with claim.
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
A minimum of four affected
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D4211
Gingivectomy Or
Gingivoplasty - One To
Three Contiguous Teeth
No
with claim.
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
One to three affected teeth
in the quadrant.
AGP_KanCare
ICF_MR Adult
D4230
Anatomical Crown
Exposure - Four Or More
Contiguous Teeth Per
Quadrant
No
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
ICF_MR Adult
D4231
Anatomical Crown
Exposure - One To Three
Teeth Per Quadrant
No
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Same date and same tooth
in conjunction with the
restorative code.
AGP_KanCare
ICF_MR Adult
D4268
Surgical Revision
Procedure, Per Tooth
No
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
Only covered after D4210.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D4341
Periodontal Scaling And
Root Planing - Four Or
More Teeth Per Quadrant
No
21
999
4
12
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D4342
Root Planing - One To
Three Teeth Per Quadrant
No
21
999
4
12
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AGP_KanCare
ICF_MR Adult
D4355
No
21
999
1
12
MONTH
AGP_KanCare
ICF_MR Adult
D5110
Complete Denture Maxillary
No
with claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5120
No
with claim
21
999
1
60
MONTH
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D5211
No
claim.
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5212
Mandibular Partial Denture
- Resin Base
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5213
Maxillary Partial Denture Cast Metal Framework
With Resin Denture Bases
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5214
- Cast Metal Framework
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5225
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5226
- Flexible Base
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5281
Removable Unilateral
Partial Denture - One
Piece Cast Metal
No
claim
21
999
1
60
MONTH
AGP_KanCare
ICF_MR Adult
D5410
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5411
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5421
No
N/A
21
999
Beneficiaries ages 21 and
over require: Preoperative
radiographs of adjacent
and opposing teeth along
with narrative of medical
necessity should be
retained in beneficiary's
chart.
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D5422
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5510
Denture Base
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
AGP_KanCare
ICF_MR Adult
D5520
Replace Missing Or
Broken Teeth - Complete
Denture (Each Tooth)
No
N/A
21
999
Teeth Covered:
1 - 32
AGP_KanCare
ICF_MR Adult
D5610
Repair Resin Denture
Base
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D5620
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D5630
Clasp
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D5640
Replace Broken Teeth Per Tooth
No
N/A
21
999
Teeth Covered: 1-32
AGP_KanCare
ICF_MR Adult
D5650
Add Tooth To Existing
Partial Denture
No
N/A
21
999
Teeth Covered:
1 - 32
AGP_KanCare
ICF_MR Adult
D5660
Add Clasp To Existing
Partial Denture
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
ICF_MR Adult
D5670
Replace All Teeth And
Acrylic On Cast Metal
Framework (Maxillary)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5671
Framework (Mandibular)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5750
No
N/A
21
999
1
24
MONTH
months of placement
AGP_KanCare
ICF_MR Adult
D5751
Reline Complete
Mandibular Denture
(Laboratory)
No
N/A
21
999
1
24
MONTH
months of placement
AGP_KanCare
ICF_MR Adult
D5760
No
N/A
21
999
1
24
MONTH
months of placement
AGP_KanCare
ICF_MR Adult
D5761
No
N/A
21
999
1
24
MONTH
months of placement
AGP_KanCare
ICF_MR Adult
D5850
Maxillary
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D5851
Mandibular
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D6100
Implant Removal, By
Report
Yes-Retro Review
med nec with claim
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
ICF_MR Adult
D6930
Denture
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D7140
Extraction, Erupted Tooth
Or Exposed Root
No
N/A
21
999
1
Period
Length
Period
Type
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D7210
Surgical Removal Or
Erupted Tooth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
and bone, removal of tooth
structure, and closure.
AGP_KanCare
ICF_MR Adult
D7220
Removal Of Impacted
Tooth - Soft Tissue
No
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
ICF_MR Adult
D7230
Removal Of Impacted
Tooth - Partially Bony
No
bitewings) and narr of med neck
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
ICF_MR Adult
D7240
Removal Of Impacted
Tooth - Completely Bony
No
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D7241
Removal Of Impacted
Tooth - Completely Bony,
Unusual Surgical
Complications
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
maxillary sinus, or aberrant
tooth position.
AGP_KanCare
ICF_MR Adult
D7250
Surgical Removal Of
Residual Tooth (Cutting
Procedure)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A–T
AS - TS (SN)
tooth.
AGP_KanCare
ICF_MR Adult
D7260
No
claim.
21
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
ICF_MR Adult
D7270
Stabilization Of
Accidentally Evulsed /
Displaced Tooth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
stabilization.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
ICF_MR Adult
D7280
Unerupted Tooth
No
with claim
21
999
AGP_KanCare
ICF_MR Adult
D7285
Biopsy Of Oral Tissue Hard (Bone, Tooth)
No
21
999
AGP_KanCare
ICF_MR Adult
D7286
Biopsy Of Oral Tissue Soft
No
21
999
AGP_KanCare
ICF_MR Adult
D7320
Conjunction With
Extractions - Four Or More
Teeth
No
with claim
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in an edentulous area. Not
covered when performed
on the same day as an
extraction for the same
tooth.
AGP_KanCare
ICF_MR Adult
D7350
Tissue Grafts)
No
with claim
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
ICF_MR Adult
D7410
Up To 1.25 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7411
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7412
Complicated
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7413
Excision Of Malignant
Lesion Up To 1.25 Cm
No
N/A
21
999
1
Period
Length
Period
Type
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Will not be payable unless
the orthodontic treatment
has been authorized as a
covered benefit for
beneficiaries 0-20.
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D7414
Lesion Greater Than 1.25
Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7415
Lesion, Complicated
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7440
Tumor - Lesion Diameter
Up To 1.25 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7441
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7450
Removal Of Benign
Odontogenic Cyst Or
Tumor - Dia Up To 1.25
Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7451
Removal Of Benign
Odontogenic Cyst Or
1.25 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7460
Removal Of Benign
Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7461
Removal Of Benign
1.25 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7471
Removal Of Lateral
Exostosis (Maxilla Or
Mandible)
No
with claim
21
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
ICF_MR Adult
D7472
Removal Of Torus
Palatinus
No
with claim
21
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
ICF_MR Adult
D7473
Removal Of Torus
Mandibularis
No
with claim
21
999
1
1
ONCE
PER
LIFETIME
01(UA), 02(LA)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D7490
Radical Resection Of
Maxilla Or Mandible
No
with claim
21
999
Area Covered:
01 (UA)
02 (LA)
AGP_KanCare
ICF_MR Adult
D7510
Abscess - Intraoral Soft
Tissue
No
N/A
21
999
service as D7511
AGP_KanCare
ICF_MR Adult
D7511
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7520
Tissue
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7521
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7530
From Mucosa
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7540
Removal Of Reaction
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7550
Partial
Ostectomy/Sequestrectom
y For Removal Of NonVital Bone
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7560
Removal Of Tooth
Fragment Or Foreign Body
Yes-Retro Review
21
999
service as D7521
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
ICF_MR Adult
D7610
(Teeth Immobilized, If
Present)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7620
Present)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7630
Mandible - Open
Reduction (Teeth
Immobilized, If Present)
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7640
Mandible - Closed
Reduction (Teeth
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7650
Malar And/Or Zygomatic
Arch - Open Reduction
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7660
Arch - Closed Reduction
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7670
Alveolus - Closed
Reduction, May Include
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7680
Facial Bones Complicated Reduction
With Fixation And Multiple
Surgical
Yes-Retro Review
21
999
AGP_KanCare
ICF_MR Adult
D7710
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7720
No
N/A
21
999
Max
Count
Period
Length
Period
Type
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
ICF_MR Adult
D7730
Mandible - Open
Reduction
No
records.
21
999
AGP_KanCare
ICF_MR Adult
D7740
Mandible - Closed
Reduction
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7750
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7760
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7770
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7780
Surgical
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7820
Closed Reduction Of
Dislocation
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7860
Arthrotomy
No
med nec with claim
21
999
AGP_KanCare
ICF_MR Adult
D7865
Arthroplasty
Yes-Retro Review
21
999
AGP_KanCare
ICF_MR Adult
D7910
Wounds Up To 5 Cm
No
N/A
21
999
Max
Count
Period
Length
Period
Type
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
ICF_MR Adult
D7911
Complicated Suture - Up
To 5 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7912
Complicated Suture Greater Than 5 Cm
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7920
Covered, Location And
Type Of Graft)
Yes-Retro Review
med nec with claim
21
999
AGP_KanCare
ICF_MR Adult
D7955
Yes-Retro Review
21
999
AGP_KanCare
ICF_MR Adult
D7960
Frenulectomy - Also
Known As Frenectomy Or
Frenotomy - Separate
Procedure
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7963
Frenuloplasty
No
N/A
21
999
Max
Count
Period
Length
Period
Type
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
1
1
LIFETIME
Area Covered:
01 (UA)
02 (LA)
ONCE PER LIFETIME. Per
location.
when the tongue has
or when the frenum
interferes with a prosthetic
appliance; or when it is the
etiology of periodontal
tissue disease.
excision or repositioning of
abervant muscle and zplasty or other local flap
closure
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D7971
Gingiva
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7980
Sialolithotomy
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7981
Excision Of Salivary Gland,
By Report
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7982
Sialodochoplasty
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D7983
Yes-Retro Review
21
999
AGP_KanCare
ICF_MR Adult
D7990
No
N/A
21
999
AGP_KanCare
ICF_MR Adult
D9212
Anesthesia
No
21
999
AGP_KanCare
ICF_MR Adult
D9220
Anesthesia - First 30
Minutes
No
21
999
D9220 and D9221 are only
billable when dental
diagnostic are provided on
the same date of service..
AGP_KanCare
ICF_MR Adult
D9221
Anesthesia - Each
No
21
999
the same date of service.
AGP_KanCare
ICF_MR Adult
D9230
Inhalation Of
Nitrous/Analgesia,
Anxiolysis
No
beneficiary records
21
999
with only diagnostic and/or
preventative services
(D0120 through D1208.
D1515 through D1150,
D9410, D9420).
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
ICF_MR Adult
D9241
Sedation/Analgesia - First
30 Minutes
No
21
999
AGP_KanCare
ICF_MR Adult
D9242
No
21
999
AGP_KanCare
ICF_MR Adult
D9310
Service Provided By
Dentist Or Physician
No
records'
21
999
AGP_KanCare
ICF_MR Adult
D9410
House/Extended Care
Facility Call
No
beneficiary records
21
999
Extended care facilities
only
AGP_KanCare
ICF_MR Adult
D9420
No
beneficiary records
21
999
Hospital facilities only
AGP_KanCare
ICF_MR Adult
D9610
Therapeutic Parenteral
Drug, Single Administration
No
Description of drugs and
parental administration with
claim
21
999
AGP_KanCare
ICF_MR Adult
D9920
Report
Yes-Retro Review
with claim
21
999
1
Period
Length
12
Period
Type
MONTH
date of service.
same provider.
One inpatient follow up per
beneficiary within a 10 day
period by same provider.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
ICF_MR Adult
D9972
External Bleaching - Per
Arch
optional
21
999
2
60
MONTH
AGP_KanCare
ICF_MR Adult
D9973
Tooth
optional
21
999
6
60
MONTH
AGP_KanCare
ICF_MR Adult
D9974
Internal Bleaching - Per
Tooth
optional
21
999
6
60
MONTH
AGP_KanCare
ICF_MR Adult
D9999
Yes-Retro Review
21
999
AGP_KanCare MFP (Money Follow the Person) Benefits
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
MFP Adult
D0120
No
N/A
21
999
AGP_KanCare
MFP Adult
D0140
No
N/A
21
999
AGP_KanCare
MFP Adult
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
21
999
1
6
MONTH
one exam (D0120, D0145,
or D0150) every six
group.
AGP_KanCare
MFP Adult
D0170
Problem Focused
No
N/A
21
999
1
12
MONTH
One per 12 months.
previously existing
radiographs.
1
Period
Length
Period
Type
6
MONTH
one exam (D0120, D0140,
D0145, D0150, D0170) per
every 6 months)
D0140, D0145, D0150,
group. Limited oral
when performed in
months)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D0210
No
N/A
21
999
1
36
AGP_KanCare
MFP Adult
D0220
Film
No
N/A
21
999
1
1
AGP_KanCare
MFP Adult
D0230
Additional Film
No
N/A
21
999
AGP_KanCare
MFP Adult
D0240
No
N/A
21
999
AGP_KanCare
MFP Adult
D0250
No
N/A
21
999
MONTH
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
DAYS
One per day. Any
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
MFP Adult
D0260
Film
No
N/A
21
999
AGP_KanCare
MFP Adult
D0270
No
N/A
21
999
AGP_KanCare
MFP Adult
D0272
No
N/A
21
999
Max
Count
Period
Length
Period
Type
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D0273
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
MFP Adult
D0274
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
MFP Adult
D0277
Films
No
N/A
21
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D0290
Bone Survey Film
No
N/A
21
999
AGP_KanCare
MFP Adult
D0321
No
N/A
21
999
AGP_KanCare
MFP Adult
D0330
Panoramic Film
No
N/A
21
999
1
36
AGP_KanCare
MFP Adult
D0460
Pulp Vitality Tests
No
N/A
21
999
3
1
DAYS
AGP_KanCare
MFP Adult
D1110
Prophylaxis - Adult
No
N/A
21
999
1
6
MONTH
AGP_KanCare
MFP Adult
D2140
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2150
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
MFP Adult
D2160
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
MONTH
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
are:
1 - 32, 51 - 82 (SN), A - T,
AS - TS (SN)
One per six months.
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D2161
Permanent
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
MFP Adult
D2330
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2331
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2332
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2335
No
N/A
21
999
1
12
MONTH
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
AGP_KanCare
MFP Adult
D2390
Crown, Anterior
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2391
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D2392
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
MFP Adult
D2393
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D2394
Posterior
No
N/A
21
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
MFP Adult
D2710
Crown - Resin-Based
No
N/A
21
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Adult
D2740
Substrate
No
N/A
21
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Adult
D2751
Metal
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2752
To Noble Metal
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2783
Crown - 3/4
Porcelain/Ceramic
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2791
Crown - Full Cast
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2792
Metal
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2910
Partial Coverage
Restoration
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2920
Recement Crown
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D2930
Tooth
No
N/A
21
999
1
24
MONTH
Teeth Covered:
A-T
AS - TS (SN)
period.
AGP_KanCare
MFP Adult
D2931
Tooth
No
N/A
21
999
1
24
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2940
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2951
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2954
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D2957
Each Additional
Tooth
No
N/A
21
999
1
60
MONTH
Teeth Covered:
1-3
14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 92 (SN)
AGP_KanCare
MFP Adult
D3110
Pulp Cap - Direct
(Excluding Final
Restoration)
No
N/A
21
999
AGP_KanCare
MFP Adult
D3220
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D3221
Teeth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
AGP_KanCare
MFP Adult
D3222
Tooth
Yes-Retro Review
bitewings), submitted with claim.
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
as preparation for
AGP_KanCare
MFP Adult
D3310
Endodontic Therapy,
Final Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Adult
D3320
Endodontic Therapy,
Final Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
MFP Adult
D3330
(Excluding Final
Restoration)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
MFP Adult
D3331
Access
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D3351
Apexification /
No
N/A
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D3352
Apexification /
No
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D3353
Apexification /
No
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D3410
Surgery - Anterior
No
21
999
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Adult
D3421
Surgery - Bicuspid (First
Root)
No
N/A
21
999
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
MFP Adult
D3425
No
N/A
21
999
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
MFP Adult
D3426
Root)
No
N/A
21
999
Teeth Covered:
1 - 5, 12 - 21
28 - 32
51 - 55 (SN)
62 - 71 (SN)
78 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D3430
Root
No
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D4210
Gingivectomy Or
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Adult
D4211
Gingivectomy Or
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AGP_KanCare
MFP Adult
D4230
Anatomical Crown
Quadrant
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
MFP Adult
D4231
Anatomical Crown
Teeth Per Quadrant
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
restorative code.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
AGP_KanCare
MFP Adult
D4268
Surgical Revision
No
N/A
Age
Min
ADDITIONAL
NOTES
Age Max
21
Max
Count
Period
Length
Period
Type
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D4341
No
N/A
21
999
4
12
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Adult
D4342
No
N/A
21
999
4
12
MONTH
AGP_KanCare
MFP Adult
D4355
No
N/A
21
999
1
12
MONTH
AGP_KanCare
MFP Adult
D6100
Implant Removal, By
Report
Yes-Retro Review
med nec with claim
21
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Adult
D6930
Denture
No
N/A
21
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Adult
D7140
Or Exposed Root
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D7210
Surgical Removal Or
Erupted Tooth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
MFP Adult
D7220
Removal Of Impacted
Tooth - Soft Tissue
Yes-Retro Review
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
MFP Adult
D7230
Removal Of Impacted
Yes-Retro Review
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
MFP Adult
D7240
Removal Of Impacted
Yes-Retro Review
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D7241
Removal Of Impacted
Unusual Surgical
Complications
Yes-Retro Review
with claim
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
tooth position.
AGP_KanCare
MFP Adult
D7250
Surgical Removal Of
Procedure)
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A–T
AS - TS (SN)
tooth.
AGP_KanCare
MFP Adult
D7260
Yes-Retro Review
claim.
21
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
MFP Adult
D7270
Stabilization Of
Displaced Tooth
No
N/A
21
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
stabilization.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
MFP Adult
D7280
Unerupted Tooth
No
N/A
21
999
AGP_KanCare
MFP Adult
D7285
No
21
999
AGP_KanCare
MFP Adult
D7286
No
21
999
AGP_KanCare
MFP Adult
D7320
Conjunction With
Teeth
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
tooth.
AGP_KanCare
MFP Adult
D7350
Tissue Grafts)
No
N/A
21
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Adult
D7410
Up To 1.25 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7411
No
N/A
21
999
AGP_KanCare
MFP Adult
D7412
Complicated
No
N/A
21
999
AGP_KanCare
MFP Adult
D7413
No
N/A
21
999
1
Period
Length
Period
Type
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Will not be payable unless
the orthodontic treatment
has been authorized as a
covered benefit for
beneficiaries 0-20.
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D7414
Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7415
Lesion, Complicated
No
N/A
21
999
AGP_KanCare
MFP Adult
D7440
Up To 1.25 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7441
No
N/A
21
999
AGP_KanCare
MFP Adult
D7450
Removal Of Benign
Odontogenic Cyst Or
Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7451
Removal Of Benign
Odontogenic Cyst Or
1.25 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7460
Removal Of Benign
Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7461
Removal Of Benign
1.25 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7471
Removal Of Lateral
Mandible)
Yes-Retro Review
with claim
21
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Adult
D7472
Removal Of Torus
Palatinus
Yes-Retro Review
with claim
21
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Adult
D7473
Removal Of Torus
Mandibularis
Yes-Retro Review
with claim
21
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Adult
D7490
Maxilla Or Mandible
Yes-Retro Review
with claim
21
999
Area Covered:
01 (UA)
02 (LA)
Area Covered:
01 (UA)
02 (LA)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
MFP Adult
D7510
Tissue
No
N/A
21
999
AGP_KanCare
MFP Adult
D7511
No
N/A
21
999
AGP_KanCare
MFP Adult
D7520
Tissue
No
N/A
21
999
AGP_KanCare
MFP Adult
D7521
No
N/A
21
999
AGP_KanCare
MFP Adult
D7530
From Mucosa
No
N/A
21
999
AGP_KanCare
MFP Adult
D7540
Removal Of Reaction
No
N/A
21
999
AGP_KanCare
MFP Adult
D7550
Partial
Bone
No
N/A
21
999
AGP_KanCare
MFP Adult
D7560
Removal Of Tooth
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D7610
Present)
No
N/A
21
999
AGP_KanCare
MFP Adult
D7620
Present)
No
N/A
21
999
Max
Count
Period
Length
Period
Type
Not covered on same date
of service as D7511
service as D7521.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
MFP Adult
D7630
Present)
No
N/A
21
999
AGP_KanCare
MFP Adult
D7640
Mandible - Closed
Reduction (Teeth
No
N/A
21
999
AGP_KanCare
MFP Adult
D7650
No
N/A
21
999
AGP_KanCare
MFP Adult
D7660
No
N/A
21
999
AGP_KanCare
MFP Adult
D7670
Alveolus - Closed
No
N/A
21
999
AGP_KanCare
MFP Adult
D7680
Reduction With Fixation
And Multiple Surgical
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D7710
No
N/A
21
999
AGP_KanCare
MFP Adult
D7720
No
N/A
21
999
AGP_KanCare
MFP Adult
D7730
No
N/A
21
999
AGP_KanCare
MFP Adult
D7740
Mandible - Closed
Reduction
No
N/A
21
999
AGP_KanCare
MFP Adult
D7750
No
N/A
21
999
AGP_KanCare
MFP Adult
D7760
No
N/A
21
999
AGP_KanCare
MFP Adult
D7770
No
N/A
21
999
Max
Count
Period
Length
Period
Type
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
MFP Adult
D7780
Reduction With Fixation
And Multiple Surgical
No
N/A
21
999
AGP_KanCare
MFP Adult
D7820
Closed Reduction Of
Dislocation
No
N/A
21
999
AGP_KanCare
MFP Adult
D7860
Arthrotomy
Yes-Retro Review
med nec with claim
21
999
AGP_KanCare
MFP Adult
D7865
Arthroplasty
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D7910
Wounds Up To 5 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7911
To 5 Cm
No
N/A
21
999
AGP_KanCare
MFP Adult
D7912
No
N/A
21
999
AGP_KanCare
MFP Adult
D7920
Type Of Graft)
Yes-Retro Review
med nec with claim
21
999
Max
Count
Period
Length
Period
Type
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
MFP Adult
D7955
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D7960
Frenulectomy - Also Known
As Frenectomy Or
Procedure
No
N/A
21
999
AGP_KanCare
MFP Adult
D7963
Frenuloplasty
No
N/A
21
999
AGP_KanCare
MFP Adult
D7971
Gingiva
No
N/A
21
999
AGP_KanCare
MFP Adult
D7980
Sialolithotomy
No
N/A
21
999
AGP_KanCare
MFP Adult
D7981
By Report
No
N/A
21
999
AGP_KanCare
MFP Adult
D7982
Sialodochoplasty
No
N/A
21
999
Max
Count
1
Period
Length
Period
Type
1
LIFETIME
Area Covered:
01 (UA)
02 (LA)
location.
when the tongue has
or when the frenum
tissue disease.
Excision of frenum with the
closure.
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D7983
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D7990
No
N/A
21
999
AGP_KanCare
MFP Adult
D9212
Anesthesia
Yes-Retro Review
with claim
21
999
AGP_KanCare
MFP Adult
D9220
Minutes
Yes-Retro Review
21
999
D D9220 and D9221 are
AGP_KanCare
MFP Adult
D9221
Anesthesia - Each
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D9230
Inhalation Of
Nitrous/Analgesia,
Anxiolysis
No
shall be maintained in beneficiary
records
21
999
(D0120 through D1208,
D9410, D9420).
AGP_KanCare
MFP Adult
D9241
30 Minutes
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D9242
Yes-Retro Review
21
999
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
AGP_KanCare
MFP Adult
D9310
Service Provided By
No
maintained in beneficiary records.
21
999
AGP_KanCare
MFP Adult
D9410
House/Extended Care
Facility Call
No
records
21
999
only.
AGP_KanCare
MFP Adult
D9420
No
records
21
999
AGP_KanCare
MFP Adult
D9610
Yes-Retro Review
21
999
AGP_KanCare
MFP Adult
D9920
Report
Yes-Retro Review
with claim
21
999
AGP_KanCare
MFP Adult
D9972
Arch
medical necessity, photo optional
21
999
1
1
Period
Length
12
60
Period
Type
MONTH
MONTH
date of service.
same provider.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Adult
D9973
Tooth
21
999
1
60
MONTH
AGP_KanCare
MFP Adult
D9974
Tooth
21
999
1
60
MONTH
AGP_KanCare
MFP Adult
D9999
Yes-Retro Review
21
999
AGP_KanCare MFP (Money Follow the Person) Frail Elderly
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
AGP_KanCare
MFP Frail
Elderly
D0120
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0140
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
65
999
1
6
MONTH
AGP_KanCare
MFP Frail
Elderly
D0170
Problem Focused
No
N/A
65
999
1
12
MONTH
1
Period
Length
Period
Type
6
MONTH
one exam (D0120, D0140,
D0145, D0150, D0170) per
every 6 months)
D0140, D0145, D0150,
group. Limited oral
when performed in
months)
one exam (D0120, D0145,
or D0150) every six
group.
One per 12 months.
previously existing
radiographs.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D0210
No
N/A
65
999
1
36
AGP_KanCare
MFP Frail
Elderly
D0220
Film
No
N/A
65
999
1
1
AGP_KanCare
MFP Frail
Elderly
D0230
Additional Film
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0240
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0250
No
N/A
65
999
MONTH
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
DAYS
One per day. Any
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
MFP Frail
Elderly
D0260
Film
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0270
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0272
No
N/A
65
999
ADDITIONAL
NOTES
Max
Count
Period
Length
Period
Type
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D0273
No
N/A
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
MFP Frail
Elderly
D0274
No
N/A
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
MFP Frail
Elderly
D0277
Films
No
N/A
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D0290
Bone Survey Film
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0321
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D0330
Panoramic Film
No
N/A
65
999
1
36
AGP_KanCare
MFP Frail
Elderly
D0460
Pulp Vitality Tests
No
N/A
65
999
3
1
DAYS
AGP_KanCare
MFP Frail
Elderly
D1110
Prophylaxis - Adult
No
N/A
65
999
1
6
MONTH
AGP_KanCare
MFP Frail
Elderly
D2140
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2150
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
MFP Frail
Elderly
D2160
Amalgam - Three
Permanent
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
MFP Frail
Elderly
D2161
Permanent
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
MONTH
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
are:
1 - 32, 51 - 82 (SN), A - T,
AS - TS (SN)
One per six months.
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D2330
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2331
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2332
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2335
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2390
Crown, Anterior
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2391
No
N/A
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D2392
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
MFP Frail
Elderly
D2393
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
MFP Frail
Elderly
D2394
Posterior
No
N/A
65
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D2710
Crown - Resin-Based
No
N/A
65
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Frail
Elderly
D2740
Substrate
No
N/A
65
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Frail
Elderly
D2751
Metal
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2752
To Noble Metal
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2783
Crown - 3/4
Porcelain/Ceramic
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2791
Crown - Full Cast
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2792
Metal
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2910
Partial Coverage
Restoration
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2920
Recement Crown
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2930
Tooth
No
N/A
65
999
1
24
MONTH
AGP_KanCare
MFP Frail
Elderly
D2931
Tooth
No
N/A
65
999
1
24
MONTH
Teeth Covered:
A-T
AS - TS (SN)
period.
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D2940
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2951
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2954
Yes-Retro Review
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D2957
Each Additional
Tooth
No
N/A
65
999
1
60
MONTH
Teeth Covered:
1-3
14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 92 (SN)
AGP_KanCare
MFP Frail
Elderly
D3110
Pulp Cap - Direct
(Excluding Final
Restoration)
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D3220
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
AGP_KanCare
MFP Frail
Elderly
D3221
Teeth
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D3222
Tooth
Yes-Retro Review
bitewings) with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
as preparation for
AGP_KanCare
MFP Frail
Elderly
D3310
Endodontic Therapy,
Final Restoration)
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Frail
Elderly
D3320
Endodontic Therapy,
Final Restoration)
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
MFP Frail
Elderly
D3330
(Excluding Final
Restoration)
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3331
Access
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3351
Apexification /
No
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3352
Apexification /
No
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D3353
Apexification /
No
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3410
Apicoectomy /
No
65
999
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
MFP Frail
Elderly
D3421
Apicoectomy /
No
N/A
65
999
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
MFP Frail
Elderly
D3425
Apicoectomy /
No
N/A
65
999
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3426
Apicoectomy /
No
N/A
65
999
Teeth Covered:
1 - 5, 12 - 21
28 - 32
51 - 55 (SN)
62 - 71 (SN)
78 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D3430
Root
No
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
AGP_KanCare
MFP Frail
Elderly
D4210
Gingivectomy Or
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
D4211
Gingivectomy Or
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AGP_KanCare
MFP Frail
Elderly
D4230
Anatomical Crown
Quadrant
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
MFP Frail
Elderly
D4231
Anatomical Crown
Teeth Per Quadrant
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
MFP Frail
Elderly
D4268
Surgical Revision
No
N/A
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D4341
No
N/A
65
999
4
Period
Length
12
Period
Type
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D4342
Yes-Retro Review
65
999
4
12
MONTH
AGP_KanCare
MFP Frail
Elderly
D4355
No
65
999
1
12
MONTH
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D5110
No
N/A
65
999
1
60
MONTH
D5120
No
N/A
65
999
1
60
MONTH
D5211
No
adjacent and opposing teeth
along with narrative of medical
necessity should be retained in
beneficiary's chart
65
999
1
60
MONTH
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D5212
- Resin Base
No
N/A
65
999
1
60
MONTH
D5213
No
N/A
65
999
1
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D5214
No
N/A
65
999
1
60
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D5225
No
N/A
65
999
1
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D5226
- Flexible Base
No
N/A
65
999
1
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D5281
Piece Cast Metal
No
N/A
65
999
1
60
MONTH
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D5410
No
N/A
65
999
D5411
No
N/A
65
999
D5421
No
N/A
65
999
D5422
No
N/A
65
999
D5510
Denture Base
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
AGP_KanCare
MFP Frail
Elderly
D5520
Replace Missing Or
No
N/A
65
999
Teeth Covered:
1 - 32
AGP_KanCare
MFP Frail
Elderly
D5610
Base
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
D5620
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D5630
Clasp
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D5640
No
N/A
65
999
Teeth Covered:
1 - 32
D5650
Partial Denture
No
N/A
65
999
Teeth Covered:
1 - 32
AGP_KanCare
MFP Frail
Elderly
D5660
Partial Denture
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
D5670
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D5671
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D5730
Denture (Chairside)
No
N/A
65
999
1
24
MONTH
AGP_KanCare
MFP Frail
Elderly
D5731
Reline Complete
Mandibular Denture
(Chairside)
No
N/A
65
999
1
24
MONTH
AGP_KanCare
MFP Frail
Elderly
D5750
No
N/A
65
999
1
24
MONTH
AGP_KanCare
MFP Frail
Elderly
D5751
Reline Complete
Mandibular Denture
(Laboratory)
No
N/A
65
999
1
24
MONTH
AGP_KanCare
MFP Frail
Elderly
D5760
No
N/A
65
999
1
24
MONTH
One per 24 months. Not
covered within 24 months
of placement. Covered for
Frail Elderly benefit plan
only.
only.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
AGP_KanCare
MFP Frail
Elderly
D5761
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D5850
Maxillary
No
N/A
65
999
D5851
Mandibular
No
N/A
65
999
D6100
Implant Removal, By
Report
Yes-Retro Review
med nec with claim
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
MFP Frail
Elderly
D6930
Denture
No
N/A
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
D7140
Or Exposed Root
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
MFP Frail
Elderly
D7210
Surgical Removal Or
Erupted Tooth
No
Preoperative radiographs must
be available
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
MFP Frail
Elderly
D7220
Removal Of Impacted
Tooth - Soft Tissue
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
1
Period
Length
Period
Type
24
MONTH
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D7230
Removal Of Impacted
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
MFP Frail
Elderly
D7240
Removal Of Impacted
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
MFP Frail
Elderly
D7241
Removal Of Impacted
Unusual Surgical
Complications
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
tooth position.
AGP_KanCare
MFP Frail
Elderly
D7250
Surgical Removal Of
Procedure)
No
records.
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
structure, and closure. Will
not be paid to the providers
or group that originally
removed the tooth.
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D7260
Yes-Retro Review
claim.
65
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
MFP Frail
Elderly
D7270
Stabilization Of
Displaced Tooth
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
stabilization.
AGP_KanCare
MFP Frail
Elderly
D7280
Unerupted Tooth
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
MFP Frail
Elderly
D7285
No
65
999
AGP_KanCare
MFP Frail
Elderly
D7286
No
65
999
AGP_KanCare
MFP Frail
Elderly
D7310
Alveoloplasty In
Conjunction With
Teeth
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Covered for Frail Elderly
benefit plan only.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D7320
Conjunction With
Teeth
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
tooth.
AGP_KanCare
MFP Frail
Elderly
D7350
Tissue Grafts)
No
N/A
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
MFP Frail
Elderly
D7410
Up To 1.25 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7411
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7412
Complicated
No
N/A
65
999
D7413
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7414
Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7415
Lesion, Complicated
No
N/A
65
999
D7440
Up To 1.25 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7441
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7450
Removal Of Benign
Odontogenic Cyst Or
Cm
No
N/A
65
999
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D7451
Removal Of Benign
Odontogenic Cyst Or
1.25 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7460
Removal Of Benign
Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7461
Removal Of Benign
1.25 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7471
Removal Of Lateral
Mandible)
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Frail
Elderly
D7472
Removal Of Torus
Palatinus
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Frail
Elderly
D7473
Removal Of Torus
Mandibularis
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
MFP Frail
Elderly
D7490
Maxilla Or Mandible
Yes-Retro Review
with claim
65
999
Area Covered:
01 (UA)
02 (LA)
AGP_KanCare
MFP Frail
Elderly
D7510
Tissue
No
N/A
65
999
Not covered on same date
of service as D7511
AGP_KanCare
MFP Frail
Elderly
D7511
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7520
Tissue
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7521
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7530
From Mucosa
No
N/A
65
999
Area Covered:
01 (UA)
02 (LA)
service as D721
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
MFP Frail
Elderly
D7540
Removal Of Reaction
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7550
Partial
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7560
Removal Of Tooth
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D7610
Present)
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7620
Present)
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7630
Mandible - Open
Reduction (Teeth
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7640
Mandible - Closed
Reduction (Teeth
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7650
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7660
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7670
Alveolus - Closed
No
N/A
65
999
ADDITIONAL
NOTES
Max
Count
Period
Length
Period
Type
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
MFP Frail
Elderly
D7680
Surgical
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7710
No
N/A
65
999
D7720
No
N/A
65
999
D7730
Mandible - Open
Reduction
No
records.
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7740
Mandible - Closed
Reduction
No
N/A
65
999
D7750
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7760
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7770
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7780
Surgical
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7820
Closed Reduction Of
Dislocation
No
N/A
65
999
D7860
Arthrotomy
Yes-Retro Review
med nec with claim
65
999
ADDITIONAL
NOTES
Max
Count
Period
Length
Period
Type
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
MFP Frail
Elderly
D7865
Arthroplasty
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D7910
Wounds Up To 5 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7911
To 5 Cm
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7912
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7920
Type Of Graft)
Yes-Retro Review
med nec with claim
65
999
AGP_KanCare
MFP Frail
Elderly
D7955
Yes-Retro Review
65
999
ADDITIONAL
NOTES
Max
Count
Period
Length
Period
Type
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
Age
Min
Age Max
AGP_KanCare
MFP Frail
Elderly
D7960
Frenulectomy - Also
Procedure
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7963
Frenuloplasty
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
D7971
Gingiva
No
N/A
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7980
Sialolithotomy
No
N/A
65
999
D7981
By Report
No
N/A
65
999
D7982
Sialodochoplasty
No
N/A
65
999
D7983
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
AGP_KanCare
MFP Frail
Elderly
D7990
No
N/A
65
999
D9212
Anesthesia
Yes-Retro Review
with claim
65
999
ADDITIONAL
NOTES
Max
Count
1
Period
Length
Period
Type
1
LIFETIME
Area Covered:
01 (UA)
02 (LA)
location.
when the tongue has
or when the frenum
tissue disease.
closure.
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
AGP_KanCare
MFP Frail
Elderly
D9220
Minutes
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D9221
Anesthesia - Each
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D9230
Inhalation Of
Nitrous/Analgesia,
Anxiolysis
No
records
65
999
D9410, D9420).
AGP_KanCare
MFP Frail
Elderly
D9241
30 Minutes
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D9242
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D9310
Service Provided By
No
65
999
AGP_KanCare
MFP Frail
Elderly
D9410
House/Extended Care
Facility Call
No
65
999
1
Period
Length
12
Period
Type
MONTH
date of service.
same provider.
only.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age Max
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Max
Count
Period
Length
Period
Type
AGP_KanCare
MFP Frail
Elderly
D9420
No
65
999
AGP_KanCare
MFP Frail
Elderly
D9610
Yes-Retro Review
65
999
AGP_KanCare
MFP Frail
Elderly
D9920
Report
Yes-Retro Review
with claim
65
999
AGP_KanCare
MFP Frail
Elderly
D9972
Arch
65
999
2
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D9973
Tooth
65
999
6
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D9974
Tooth
65
999
6
60
MONTH
AGP_KanCare
MFP Frail
Elderly
D9999
Yes-Retro Review
65
999
AGP_KanCare HCBS Frail Elderly
HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an
approved 'Crisis Exception' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D0120
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0140
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0150
Comprehensive Oral
Evaluation - New Or
Established Patient
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0170
Problem Focused
No
N/A
65
999
Max
Count
Period
Length
1
1
6
Period
Type
MONTH
6
MONTH
12
MONTH
one exam (D0120, D0140,
D0145, D0150, D0170) per
every 6 months)
D0140, D0145, D0150,
group. Limited oral
when performed in
months)
one exam (D0120, D0145,
or D0150) every six
group.
One per 12 months.
previously existing
radiographs.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
AGP_KanCare
HCBS Frail
Elderly
D0210
No
N/A
65
999
1
36
AGP_KanCare
HCBS Frail
Elderly
D0220
Film
No
N/A
65
999
1
1
AGP_KanCare
HCBS Frail
Elderly
D0230
Additional Film
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0240
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0250
No
N/A
65
999
Period
Type
MONTH
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
DAYS
One per day. Any
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D0260
Film
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0270
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D0272
No
N/A
65
999
Max
Count
Period
Length
Period
Type
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D0273
No
N/A
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
HCBS Frail
Elderly
D0274
No
N/A
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AGP_KanCare
HCBS Frail
Elderly
D0277
Films
Yes-Crisis Exception
HCBS Crisis Exception Narrative
65
999
(D0220 - D0340)
series and are not
reimbursed.
(D0270, D0272, D0273,
billing group.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D0290
Bone Survey Film
65
999
AGP_KanCare
HCBS Frail
Elderly
D0321
65
999
AGP_KanCare
HCBS Frail
Elderly
D0330
Panoramic Film
No
N/A
65
999
1
36
AGP_KanCare
HCBS Frail
Elderly
D0460
Pulp Vitality Tests
65
999
3
1
DAYS
AGP_KanCare
HCBS Frail
Elderly
D1110
Prophylaxis - Adult
No
N/A
65
999
1
6
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2140
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2150
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
HCBS Frail
Elderly
D2160
Amalgam - Three
Permanent
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
MONTH
(D0220 - D0340)
series and are not
reimbursed.
(D0220 - D0340)
series and are not
reimbursed.
following are also
D0330 and D0272
D0330 and D0273
D0330 and D0274
D0330 and D0277
are:
1 - 32, 51 - 82 (SN), A - T,
AS - TS (SN)
One per six months.
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D2161
Permanent
65
999
1
12
MONTH
Teeth Covered:
1 - 32,51 - 82 (SN),A T,AS - TS (SN)
AGP_KanCare
HCBS Frail
Elderly
D2330
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2331
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2332
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2335
65
999
1
12
MONTH
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
AGP_KanCare
HCBS Frail
Elderly
D2390
Crown, Anterior
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2391
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2392
65
999
1
12
MONTH
Teeth Covered:
6 - 11, 22 - 27, 56 - 61
(SN), 72 - 77 (SN), C - H,
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D2393
65
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
HCBS Frail
Elderly
D2394
Posterior
65
999
1
12
MONTH
Teeth Covered:
1 - 5, 12 - 21, 28 - 32, 51 55 (SN), 62 - 71 (SN), 78 82 (SN,) A, B, I - L, S, T,
AGP_KanCare
HCBS Frail
Elderly
D2710
Crown - Resin-Based
and Pre-op x-rays of adj and
opposing teeth, fill x-ray.
65
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2740
Substrate
opposing teeth, fill x-ray
65
999
1
60
MONTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2751
Metal
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2752
To Noble Metal
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D2783
Crown - 3/4
Porcelain/Ceramic
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2791
Crown - Full Cast
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2792
Metal
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2910
Partial Coverage
Restoration
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2920
Recement Crown
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2930
Tooth
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D2931
Tooth
65
999
1
24
MONTH
Teeth Covered:
A-T
AS - TS (SN)
period.
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D2940
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2951
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2954
65
999
1
60
MONTH
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D2957
Each Additional
Tooth
65
999
1
60
MONTH
Teeth Covered:
1-3
14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 92 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3110
Pulp Cap - Direct
(Excluding Final
Restoration)
65
999
AGP_KanCare
HCBS Frail
Elderly
D3220
65
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
HCBS Frail
Elderly
D3221
Teeth
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS
tooth.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D3222
Tooth
and Pre-operative x-rays
(excluding bitewings)
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
as preparation for
AGP_KanCare
HCBS Frail
Elderly
D3310
Endodontic Therapy,
Final Restoration)
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3320
Endodontic Therapy,
Final Restoration)
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3330
(Excluding Final
Restoration)
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3331
Access
and Pre-operative x-rays
(excluding bitewings)
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3351
Apexification /
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3352
Apexification /
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D3353
Apexification /
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3410
Apicoectomy /
65
999
Teeth Covered:
6 - 11
22 - 27
56 - 61 (SN)
72 - 77 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3421
Apicoectomy /
65
999
Teeth Covered:
4, 5, 12, 13
20, 21, 28, 29
54 (SN)
55 (SN)
62 (SN)
63 (SN)
70 (SN)
71 (SN)
78 (SN), 79 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3425
Apicoectomy /
65
999
Teeth Covered:
1 - 3, 14 - 19
30 - 32
51 - 53 (SN)
64 - 69 (SN)
80 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3426
Apicoectomy /
65
999
Teeth Covered:
1 - 5, 12 - 21
28 - 32
51 - 55 (SN)
62 - 71 (SN)
78 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D3430
Root
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D4210
Gingivectomy Or
and Pre-op x-rays, perio charting,
photo (optional)
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
AGP_KanCare
HCBS Frail
Elderly
D4211
Gingivectomy Or
and Pre-op x-rays, perio charting,
photo (optional) with claim
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AGP_KanCare
HCBS Frail
Elderly
D4230
Anatomical Crown
Quadrant
and Pre operative x-rays with
claim
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
(D2140 - D2957).
AGP_KanCare
HCBS Frail
Elderly
D4231
Anatomical Crown
Teeth Per Quadrant
and Pre operative x-rays with
claim
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
restorative code.
AGP_KanCare
HCBS Frail
Elderly
D4268
Surgical Revision
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D4341
and Periodontal charting and preop x-rays with claim
65
999
4
12
Period
Type
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D4342
65
999
4
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D4355
65
999
1
12
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5110
opposing teeth, trmt plan
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5120
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5211
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5212
- Resin Base
65
999
1
60
MONTH
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
in the quadrant.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D5213
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5214
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5225
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5226
- Flexible Base
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5281
Piece Cast Metal
65
999
1
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5410
65
999
AGP_KanCare
HCBS Frail
Elderly
D5411
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D5421
65
999
AGP_KanCare
HCBS Frail
Elderly
D5422
65
999
AGP_KanCare
HCBS Frail
Elderly
D5510
Denture Base
65
999
Area covered:
01 (UA)
02 (LA)
AGP_KanCare
HCBS Frail
Elderly
D5520
Replace Missing Or
65
999
Teeth Covered:
1 - 32
AGP_KanCare
HCBS Frail
Elderly
D5610
Base
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
HCBS Frail
Elderly
D5620
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
HCBS Frail
Elderly
D5630
Clasp
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
HCBS Frail
Elderly
D5640
65
999
Teeth Covered:
1 - 32
AGP_KanCare
HCBS Frail
Elderly
D5650
Partial Denture
65
999
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D5660
Partial Denture
65
999
AGP_KanCare
HCBS Frail
Elderly
D5670
65
999
AGP_KanCare
HCBS Frail
Elderly
D5671
65
999
AGP_KanCare
HCBS Frail
Elderly
D5730
Denture (Chairside)
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5731
Reline Complete
Mandibular Denture
(Chairside)
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5750
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5751
Reline Complete
Mandibular Denture
(Laboratory)
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5760
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5761
65
999
1
24
MONTH
AGP_KanCare
HCBS Frail
Elderly
D5850
Maxillary
65
999
AGP_KanCare
HCBS Frail
Elderly
D5851
Mandibular
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
only.
only.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D6100
Implant Removal, By
Report
Yes-Retro Review
med neck with claim
65
999
Teeth Covered:
1 - 32
51 - 82 (SN)
AGP_KanCare
HCBS Frail
Elderly
D6930
Denture
65
999
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
HCBS Frail
Elderly
D7140
Or Exposed Root
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
HCBS Frail
Elderly
D7210
Surgical Removal Or
Erupted Tooth
No
N/A
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
tooth not covered.
AGP_KanCare
HCBS Frail
Elderly
D7220
Removal Of Impacted
Tooth - Soft Tissue
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D7230
Removal Of Impacted
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
HCBS Frail
Elderly
D7240
Removal Of Impacted
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
HCBS Frail
Elderly
D7241
Removal Of Impacted
Unusual Surgical
Complications
Yes-Retro Review
with claim
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
tooth position.
AGP_KanCare
HCBS Frail
Elderly
D7250
Surgical Removal Of
Procedure)
No
records.
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A–T
AS - TS (SN)
tooth.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D7260
Yes-Retro Review
claim.
65
999
1
1
LIFETIME
PER
TOOTH
AGP_KanCare
HCBS Frail
Elderly
D7270
Stabilization Of
Displaced Tooth
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
A-T
AS - TS (SN)
stabilization.
AGP_KanCare
HCBS Frail
Elderly
D7280
Unerupted Tooth
with Pre-op x-rays, narr of med
nec
65
999
1
1
LIFETIME
PER
TOOTH
Teeth Covered:
1 - 32
51 - 82 (SN)
tooth not covered.
AGP_KanCare
HCBS Frail
Elderly
D7285
No
65
999
AGP_KanCare
HCBS Frail
Elderly
D7286
No
65
999
AGP_KanCare
HCBS Frail
Elderly
D7310
Alveoloplasty In
Conjunction With
Teeth
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
Covered for Frail Elderly
benefit plan only.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
AGP_KanCare
HCBS Frail
Elderly
D7320
Conjunction With
Teeth
nec
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
tooth.
AGP_KanCare
HCBS Frail
Elderly
D7350
Tissue Grafts)
nec
65
999
Per quadrant:
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AGP_KanCare
HCBS Frail
Elderly
D7410
Up To 1.25 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7411
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7412
Complicated
No
N/A
65
999
D7413
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7414
Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7415
Lesion, Complicated
No
N/A
65
999
D7440
Up To 1.25 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7441
No
N/A
65
999
1
1
Period
Type
DAYS
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D7450
Removal Of Benign
Odontogenic Cyst Or
Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7451
Removal Of Benign
Odontogenic Cyst Or
1.25 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7460
Removal Of Benign
Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7461
Removal Of Benign
1.25 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7471
Removal Of Lateral
Mandible)
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
HCBS Frail
Elderly
D7472
Removal Of Torus
Palatinus
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
HCBS Frail
Elderly
D7473
Removal Of Torus
Mandibularis
Yes-Retro Review
with claim
65
999
1
1
ONCE
PER
LIFETIME
AGP_KanCare
HCBS Frail
Elderly
D7490
Maxilla Or Mandible
Yes-Retro Review
with claim
65
999
Area Covered:
01 (UA)
02 (LA)
AGP_KanCare
HCBS Frail
Elderly
D7510
Tissue
No
N/A
65
999
service as D7511
AGP_KanCare
HCBS Frail
Elderly
D7511
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7520
Tissue
No
N/A
65
999
Area Covered:
01 (UA)
02 (LA)
service as D7521.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D7521
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7530
From Mucosa
No
N/A
65
999
D7540
Removal Of Reaction
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7550
Partial
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7560
Removal Of Tooth
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D7610
Present)
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7620
Present)
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7630
Mandible - Open
Reduction (Teeth
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7640
Mandible - Closed
Reduction (Teeth
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7650
No
N/A
65
999
Max
Count
Period
Length
Period
Type
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D7660
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7670
Alveolus - Closed
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7680
Surgical
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7710
No
N/A
65
999
D7720
No
N/A
65
999
D7730
Mandible - Open
Reduction
No
records.
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7740
Mandible - Closed
Reduction
No
N/A
65
999
D7750
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7760
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7770
No
N/A
65
999
Max
Count
Period
Length
Period
Type
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D7780
Surgical
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7820
Closed Reduction Of
Dislocation
No
N/A
65
999
D7860
Arthrotomy
Yes-Retro Review
med nec with claim
65
999
AGP_KanCare
HCBS Frail
Elderly
D7865
Arthroplasty
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D7910
Wounds Up To 5 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7911
To 5 Cm
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7912
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7920
Type Of Graft)
Yes-Retro Review
med nec with claim
65
999
AGP_KanCare
HCBS Frail
Elderly
D7955
nec
65
999
Max
Count
Period
Length
Period
Type
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
as D7140, D7210, D7220,
D7230, D7240, D7241, or
D7250.
Area covered:
01 (UA)
02 (LA)
10 (UR)
20 (UL)
30 (LL)
40 (LR)
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
AGP_KanCare
HCBS Frail
Elderly
D7960
Frenulectomy - Also
Procedure
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7963
Frenuloplasty
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
D7971
Gingiva
No
N/A
65
999
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
AGP_KanCare
HCBS Frail
Elderly
D7980
Sialolithotomy
No
N/A
65
999
D7981
By Report
No
N/A
65
999
D7982
Sialodochoplasty
No
N/A
65
999
D7983
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D7990
No
N/A
65
999
Max
Count
Period
Length
1
1
Period
Type
LIFETIME
Area Covered:
01 (UA)
02 (LA)
location.
when the tongue has
or when the frenum
tissue disease.
closure.
Teeth Covered:
1 - 32
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
AGP_KanCare
HCBS Frail
Elderly
D9212
Anesthesia
Yes-Retro Review
with claim
65
999
AGP_KanCare
HCBS Frail
Elderly
D9220
Minutes
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D9221
Anesthesia - Each
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D9230
Inhalation Of
Nitrous/Analgesia,
Anxiolysis
No
records
65
999
D9410, D9420).
AGP_KanCare
HCBS Frail
Elderly
D9241
30 Minutes
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D9242
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D9310
Service Provided By
No
65
999
1
12
Period
Type
MONTH
date of service.
same provider.
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
ADDITIONAL
NOTES
Product
Code
Code Description
Auth Required
Reqd Docs
Age Max
Max
Count
Period
Length
Period
Type
AGP_KanCare
HCBS Frail
Elderly
D9410
House/Extended Care
Facility Call
No
records.
65
999
only.
AGP_KanCare
HCBS Frail
Elderly
D9420
No
records.
65
999
AGP_KanCare
HCBS Frail
Elderly
D9610
Yes-Retro Review
65
999
AGP_KanCare
HCBS Frail
Elderly
D9920
Report
Yes-Retro Review
with claim
65
999
AGP_KanCare
HCBS Frail
Elderly
D9972
Arch
65
999
2
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D9973
Tooth
65
999
6
60
MONTH
AGP_KanCare
HCBS Frail
Elderly
D9974
Tooth
65
999
6
60
MONTH
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code Description
Auth Required
Reqd Docs
AGP_KanCare
HCBS Frail
Elderly
D9999
HCBS Crisis Exception Narrative.
narrative of medical necessity.
Age
Min
ADDITIONAL
NOTES
Age Max
65
999
Max
Count
Period
Length
Period
Type

Scion Dental KanCare Provider Manual

Transcription

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