DENTAQUEST OF ARIZONA, LLC
DENTAL PROVIDER SERVICE AGREEMENT
THIS AGREEMENT, effective as of date executed by DentaQuest (“Effective Date”), is made between
DENTAQUEST OF ARIZONA, LLC (hereinafter referred to as "DentaQuest") and
Yavapai County Community Health Services (hereinafter referred to as ("Provider").
(Business Name as appears on W-9)
WHEREAS, DentaQuest arranges for the delivery of dental services to Members of prepaid healthcare
plans and employer groups contracting with DentaQuest; and
WHEREAS, Provider, has an unrestricted license to practice dentistry in the State of Arizona and desires to
provide dental services pursuant to the terms and conditions of this Agreement;
NOW, THEREFORE, in consideration of the above and the promises hereinafter contained, the parties
hereby agree as follows:
1.
Definitions
(a)
“AHCCCS” means the Arizona Health Care Cost Containment System, as described in A.R.S.
Section 36-2901, et seq., which is composed of the Administration, contractors, subcontractors
and other providers entering into arrangement through which health care services are provided to
eligible persons.
(b)
“Agreement” means this Agreement between DentaQuest and Provider, including all attachments
hereto.
(c)
“Covered Services” is a dental service or supply that satisfies all of the following criteria:
1.
provided or arranged by a Participating Provider to a Member;
2.
authorized by DentaQuest in accordance with the Plan Certificate; and
3.
submitted to DentaQuest according to DentaQuest’s filing requirements; and
4.
limited to the most professionally recognized standards of dental practice within the
service area and applicable policies and procedures.
(d)
“Medically Necessary” means those Covered Services provided by a physician or other licensed
practitioner of the healing arts within the scope of their practice under State law to prevent disease,
disability and other adverse health conditions or their progression, or prolong life. In order to be
Medically Necessary, the service or supply for medical illness or injury must be determined by
Plan or its designee in its judgment to be a Covered Service which is required and appropriate in
accordance with AHCCCS law, regulations, guidelines and accepted standards of medical practice
in the community.
(e)
“Member” means any individual who is eligible to receive Covered Services pursuant to a contract
and the eligible dependents of such individuals.
(f)
“Participating Provider” is a dental professional or facility or other entity, including Provider that
has entered into a written agreement with DentaQuest, directly or through another entity, to
provide dental services to selected groups of Members.
(g)
“Plan” is an insurer, health maintenance organization or any other entity that is an organized
system which combines the delivery and financing of health care and which provides basic health
services to enrolled members.
(h)
“Plan Certificate” means the document that outlines the benefits available to Members.
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2.
3.
(i)
“Provider” means the undersigned health professional or any other entity that has entered into a
written agreement with DentaQuest to provide certain health services to Members. Each Provider
shall have its own distinct tax identification number.
(j)
“Provider Dentist” means a doctor of dentistry, duly licensed and qualified under the applicable
laws, who practices as a shareholder, partner, or employee of Provider.
Obligations of DentaQuest
(a)
Operations. DentaQuest shall conduct the day-to-day administrative operations of DentaQuest,
including but not limited to: drafting and negotiating contracts and provider agreements with
Providers, making benefit determinations; conducting actuarial analyses; setting, collecting and
accounting for fixed periodic payments; processing claims; regulatory compliance and reporting;
and marketing DentaQuest. State and federal programs are responsible for enrollment, reenrollment and disenrollment of Members
(b)
Directories. DentaQuest shall maintain a listing of Participating Providers and may include
Provider’s participation in Plan’s network in provider directories and/or other publications
intended for use of Members, subject to approval by Plan.
(c)
Benefit Changes. DentaQuest shall notify Provider of changes in benefit provisions offered by the
Plan.
(d)
Quality Improvement. DentaQuest shall operate, at its own expense, quality assurance, utilization
review and Member grievance programs.
(e)
Payment Processing. DentaQuest shall transmit payments to Provider in accordance with the
terms and conditions of this Agreement, or as may otherwise be agreed upon between the parties
in writing.
(f)
Regulatory Compliance. Provider and employees and agents must meet the minimum
requirements for participation in the Medicaid program as required by State and Federal
regulations..
(g)
Access to Care. DentaQuest shall conduct its administrative operations in a manner that does not
encourage Provider to jeopardize Member’s access to care or the appropriate delivery of Covered
Services to Members
Provider Obligations
(a)
Provision of Services. Provider shall render to Members all Covered Services and continue to
provide Covered Services to Members. After the date of termination from participation, upon the
request of DentaQuest, Provider shall continue to provide Covered Services to Members for a
period not to exceed one hundred and twenty (120) days during which time payment will be made
pursuant to Attachments for Covered Services provided.
(b)
Submission of Claims. Provider shall submit claims for dental services to DentaQuest in a manner
and format prescribed by DentaQuest. Provider understands that failure to submit claims or failure
to submit requested documentation within 180 days will result in loss of reimbursement for
services provided. Provider shall submit claims electronically to DentaQuest. If unable to submit
electronic claims, paper claims must be submitted on a standard ADA claim form or a format that
has been approved by DentaQuest in advance. Provider agrees to accept electronic payment and
electronic remittance if/when available.
(c)
Non-discrimination. Provider shall not discriminate in the treatment or quality of services
provided to Members on the basis of race, color, religion, sex, sexual orientation, age, disability,
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national origin, Vietnam-era veteran’s status, ancestry, health status or need for health services of
such Members and without regard to source of payments made for health services rendered to such
Members. Provider shall make their services accessible to Members during the same hours and
with the same intensity as they do to non-Members.
Provider agrees to comply with all applicable federal and state laws relating to non-discrimination
and equal employment opportunity, including the Civil Rights Act of 1964, regulations issued
pursuant to that Act and provision of Executive Order 11246 dated September 26, 1965. Provider
agrees to provide physical and program accessibility of dental services to persons with physical
and sensory disabilities pursuant to Section 504 of the Rehabilitation Act of 1973, as amended (29
U.S.C. 794), all requirements imposed by any applicable DHFS regulations (45 C.F.R. Part 84) of
CMS regulation (42 C.F.R. Parts 417 and 434) and all guidelines and interpretations issued
pursuant thereto.
(d)
Policies and Procedures. Provider agrees to comply with any and all policies, rules and
regulations of DentaQuest as they may exist from time to time including, but not limited to, claims
processing, credentialing, quality or cost containment standards established by DentaQuest and
Plans. Provider agrees to refer patients that require covered specialty services (oral surgery,
endodontics, prosthetics, and orthodontics) that Provider does not perform, only to dental
specialists designated by DentaQuest.
(e)
Member Advisement: MHP has no policies that would prohibit, or otherwise restrict, a health care
professional acting within the lawful scope of practice, from advising or advocating on behalf of a
member who is his or her patient, for the following:
(i) The member’s health status, medical care, or treatment options, including any
alternative treatment that may be self-administered.
(ii) Any information the member needs in order to decide among all relevant treatment
options.
(iii) The risks, benefits, and consequences of treatment or non-treatment.
(iv) The member’s right to participate in decisions regarding his or her health care,
including the right to refuse treatment, and to express preferences about future
treatment decisions. (42 CFR 438.102).
(f)
Records. Provider agrees to:
1.
Maintain adequate dental/medical, financial and administrative records related to covered
dental services rendered by Provider in accordance with federal and state law.
2.
Safeguard all information about Members according to applicable state and federal laws
and regulations. All material and information, in particular information relating to
Members or potential Members, which is provided to or obtained by or through
Provider’s performance under this Agreement, whether verbal, written, tape, or
otherwise, shall be reported as confidential information to the extent confidential
treatment is provided under state and federal laws. Provider shall not use any information
so obtained in any manner except as necessary for the proper discharge of his/her
obligations and securement of his/her rights under this Agreement. Neither DentaQuest
nor Provider shall share confidential information with a Member’s employer absent the
Member’s consent for such disclosure. Provider agrees to comply with the requirements
of the Health Insurance Portability and Accountability Act (“HIPAA”) relating to the
exchange of information and shall cooperate with DentaQuest in its efforts to ensure
compliance with the privacy regulations promulgated under HIPAA and other related
privacy laws. Provider and DentaQuest acknowledge that the activities conducted to
perform the obligations undertaken in this Agreement are or may be subject to HIPAA as
well as the regulations promulgated to implement HIPAA. Provider and DentaQuest
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3.
4.
5.
6.
7.
8.
9.
10.
(g)
agree to conduct their respective activities, as described herein, in accordance with the
applicable provisions of HIPAA and such implementing regulations. Provider and
DentaQuest further agree that, to the extent HIPAA or such implementing regulations
require amendments(s) hereto, Provider and DentaQuest shall conduct good faith
negotiations to amend this Agreement. Provider shall maintain adequate dental/medical,
financial and administrative records related to covered dental services rendered by
Provider in accordance with federal and state law.
To cooperate and provide Plan, DentaQuest, government agencies and any external
review organizations (“Oversight Entities”) with access to each Member’s dental records
for the purposes of quality assessment, service utilization and quality improvement,
investigation of Member complaints or grievances or as otherwise is necessary or
appropriate
To provide such information and data, including, but not limited to, encounter,
utilization, referral and other data, that Oversight Entities may require.
To provide, at no cost to the Member or the Member’s new or different dental provider,
all Member’s dental/medical records no later than fourteen (14) calendar days following
the written request. Upon written request by a Member, Provider agrees to transfer the
information in such Member's health care records to the person specified by the Member
at no charge.
That any and all Member records will be maintained for a period not less than ten (10)
years, or minimum required by state, following the termination of this Agreement or, if
such records are under review or audit, until such review or audit is complete.
That all records shall be made available for fiscal audit, medical audit, medical review,
utilization review and other periodic monitoring upon request of Oversight Entities at no
cost to the requesting entity.
Upon termination of this Agreement for any reason, to make available to any Oversight
Entities, in a useable form, all records, whether dental/medical or financial, related to
Provider’s activities undertaken pursuant to the terms of this Agreement at no cost to the
requesting entity.
That any Oversight Entities, including but not limited to DSS, the Attorney General of
the State of Arizona, the state fraud agency, the United States Department of Health and
Human Services ("HHS"), the Comptroller General of the United States, and/or their duly
authorized representatives shall have access to any books, documents, papers and records
which are related to this Agreement for the purpose of making audit, examination,
excerpts and transcriptions; provided, however, that those records detailing health care
status and/or treatment of specific Members eligible for coverage of health care/dental
services under Title XVIII of the Social Security Act need not be made available to the
Comptroller General of the United States.
That Provider shall allow duly authorized agents or representatives of Oversight Entities,
during normal business hours, access to Provider’s premises to inspect, audit, monitor or
otherwise evaluate the performance of Provider’s contractual activities and shall
forthwith produce all records requested as part of such review or audit. In the event right
of access is requested under this paragraph, Provider shall, upon request, provide and
make available staff to assist in the audit or inspection effort, and provide adequate space
on the premises to reasonably accommodate personnel conducting the audit or
inspections effort. All inspections or audits shall be conducted in a manner as will not
unduly interfere with the performance of Provider’s activities. All information so
obtained will be accorded confidential treatment as provided under applicable law.
Oversight Entities and/or their duly authorized representatives shall be allowed access to
evaluate through inspection or other means, the quality, appropriateness and timeliness of
services performed under this Agreement.
Authority of Provider. Provider represents and warrants that it has full authority to bind those
providers listed as Provider Dentist to the terms and conditions of this Agreement.
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4.
5.
(h)
Insurance. Provider shall procure and maintain at their own cost, liability insurance with limits as
otherwise required by law. Provider shall provide evidence of such coverage to DentaQuest upon
the execution of this Agreement and thereafter as requested by DentaQuest.
(i)
Clinical Laboratory Improvement Amendments. Provider shall refer all authorized laboratory
tests and procedures to a laboratory that has been issued (A) either a certificate of registration
under The Clinical Laboratory Improvement Amendments (“CLIA”), a certificate waiver under
CLIA, or a certificate of accreditation under CLIA, and (B) a CLIA identification number. A
laboratory that has been issued a certificate of waiver may only perform the tests and procedures
permitted under its waiver.
(j)
AHCCCS Minimum Subcontract Provisions. AHCCCS Minimum Subcontract Provisions are
attached to this Agreement as Attachment B and are incorporated herein by this reference. For
purposes of the requirements set forth in Attachment B, Plan is the Contractor and DentaQuest and
its Participating Providers are the Subcontractor. DentaQuest and its Participating Providers agree
to fully comply with all terms and conditions set forth in Attachment B.
(k)
AHCCCS Number. Provider Dentist shall have his/her own distinct Arizona AHCCCS number.
(l)
Appointment Status. Provider shall ensure Members are offered appointments according to
Arizona requirements; 45 days routine, 72 hours urgent, and 24 hours emergent. Provider shall
ensure that a member's waiting time after arrival in a provider’s office is no more than 45 minutes,
except when the Provider is unavailable due to an emergency.
Professional Requirements
(a)
Licensure. Provider and employees or agents rendering services to Members shall be
appropriately licensed to render such services as required by state or federal law or regulatory
agencies, and such licenses shall be maintained in good standing. Provider shall provide
DentaQuest a copy of said license(s) upon execution of this Agreement.
(b)
Restriction of Licensure. Provider shall notify DentaQuest within two (2) business days of the
loss or restriction of his/her DEA permit or dentistry license or any other action that limits or
restricts Provider’s ability to practice dentistry.
(c)
Professional Training. Provider and all employees or agents rendering services to Members shall
possess the education, skills, training, physical and mental health status, and other qualifications
necessary to provide quality dental patient care.
(d)
Professional Standards. Provider and employees or agents rendering services to Members shall
provide dental care which meets or exceeds the standard of care for dentists in the region and shall
comply with all standards for dentists as established by any state or federal law or regulation.
(e)
Continuing Education. Provider and employees or agents rendering services to Members shall
comply with continuing education standards as required by state or federal law or regulatory
agencies.
(f)
Regulatory Compliance. Provider must meet the minimum requirements for participation in the
Medicaid program as provided by the State.
Payment Arrangement
(a)
Compensation. Contingent upon receipt of payment from Plan, DentaQuest shall pay Provider
according to Attachments.
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(b)
Hold Harmless. Provider agrees and warrants that in no event, including, but not limited to,
nonpayment by DentaQuest, DentaQuest insolvency, or breach of this Agreement, shall Provider
bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or
have any recourse against any Member or persons acting on their behalf for providing Covered
Services. This provision does not prohibit Provider from seeking to collect co-insurance,
copayments or deductibles from Members or fees for non-covered services delivered on a fee-forservice basis to Members as well as services received by ineligible persons in accordance with the
terms of the applicable Plan Certificate. Provider agrees that they shall hold the Members harmless
and shall not bill the Member for non-covered services if the services are not covered as a result of
any error or omission by Provider.
Provider also agrees that this hold harmless and warranty provision herein shall:
1.
2.
survive the termination of the Agreement regardless of the cause giving rise to
termination, and
supersede any oral or written contract agreement heretofore entered into between
Provider, DentaQuest, Plan and Members or designees.
Provider also agrees to hold the State of Arizona, Members and the state agencies financially
harmless from unpaid claims for Covered Services and not seek payment from the State of
Arizona, Members or state agencies if DentaQuest will not pay for Covered Services performed by
Provider under this Agreement.
(c)
Notification of Default. Provider agrees to notify Plan immediately of any payment defaults by
DentaQuest relating to Covered Services rendered. In the event of such payment default by
DentaQuest and at Plan’s option, Provider agrees to continue rendering Covered Services
hereunder so long as payments due Provider for Covered Services rendered after Plan’s exercise of
such option are made directly to Provider by Plan and until a date specified by Plan but no later
than 120 days after Plan’s exercise of such option. Provider shall agree that any such payments
during such time period shall be made, at Plan’s election, in accordance with the reimbursement
terms set forth in this Agreement, in accordance with Plan's maximum fee schedule in effect at the
time of service, or at the AHCCCS maximum allowable.
(d)
Co-payment Limits and Member Charges For Noncovered Services. No deductibles or copayments are permitted for Medicaid covered services. A provider shall be permitted to charge an
eligible Member for goods or services which are not covered only if the Member knowingly elects
to receive the goods or services and enters into an agreement in writing to pay for such goods or
services prior to receiving them. For purposes of this section noncovered services are services not
covered under the Medicaid state plan, services which are provided in the absence of appropriate
authorization and services which are provided out-of-network unless otherwise specified in the
contract, policy or regulation (e.g., family planning, mental health or emergency room services.
(e)
Coordination of Benefits. Provider shall notify DentaQuest whenever he/she has reason to believe
a Member may be entitled to coverage under any other health benefit plan and shall assist
DentaQuest in obtaining information for the coordination of benefits when a Member holds other
coverage. If a Member is also covered by another dental plan, and DentaQuest determines it is the
primary carrier, the Provider agrees that DentaQuest’s obligation to Provider will not exceed the
compensation described in this Agreement for the Covered Services in question. If a Member is
also covered by another health benefit plan and DentaQuest determines that it is the secondary
carrier, the Provider agrees that DentaQuest’s obligation shall not exceed the compensation
described in the Agreement for the Covered Services in question and that Provider will refund
(reduced by any payments the Member may have made to Provider) the aggregate compensation
Provider received from the other health benefits plan for the Covered Services in question.
(f)
Other Coverage. Provider agrees that payment defined in Attachments shall be his/her sole
compensation for rendering Covered Services to Members. All other monies received by him/her
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from any other worker’s compensation and/or auto, health, property/casualty insurance company
must be reported and turned over to the DentaQuest subrogation department.
6.
(g)
Missed Appointment. Provider shall not bill, charge, collect a deposit from, seek compensation,
remuneration or reimbursement from or have any recourse against a Member or persons acting on
their behalf for missed appointments. Provider shall not be required to accept or continue
treatment of a Member with whom Provider feels he/she cannot establish and/or maintain a
professional relationship, or is beyond the scope of Provider’s expertise or ability.
(h)
Plan Reimbursement. Compensation of Provider by DentaQuest is subject to, and dependent
upon, DentaQuest’s receipt of proper claims payment from Plan. In the event of nonpayment by
Plan, DentaQuest reserves the right to withhold or recover payment to Provider for all claims not
paid by Plan. Once DentaQuest has received the outstanding amount for such claims from Plan,
DentaQuest will reimburse Provider according to the terms of this Agreement.
Quality Management
(a)
Cooperation with Quality Programs. Provider shall cooperate with and participate in the
utilization review, quality assurance, credentialing, grievance, peer review, claims processing, and
audit procedures of DentaQuest, and shall comply with all final determinations rendered by such
procedures.
(b)
Re-credentialing. Provider shall cooperate with the re-evaluation of their credentials at such
intervals, as DentaQuest shall determine, but not more frequently than every three years. Such
evaluation may take into account a review of Provider's past performance and practice patterns,
and a review of dental records and evaluations pertaining to Provider's participation in the delivery
of dental care.
(c)
Audit of Records. DentaQuest, Plan and all applicable state and federal agencies shall have access
at reasonable times and upon demand, to inspect the books, records and papers of Provider for the
purpose of auditing and evaluating and determining on a concurrent or retrospective basis the
necessity or appropriateness of health services provided to Members. DentaQuest, Plan or state
and federal agencies or their designees shall also have the right to inspect, upon demand and at
reasonable times, Provider’s facilities pursuant to quality management programs or peer review
programs. Provider shall provide copies of medical records to DentaQuest, Plan or state and
federal agencies or their designees upon request. Copying and delivery expenses associated with
compliance with this Agreement shall be the responsibility of Provider.
(d)
Plan and Regulatory Agency Oversight. The Provider acknowledges and agrees that nothing in
the Agreement shall be construed to limit: (a) the authority of the Plan to ensure the Provider’s
participation in and compliance with Plan’s quality assurance, utilization management, member
grievance and other systems and procedures; (b) any applicable regulatory agency’s authority to
monitor the effectiveness of such systems and procedures; or (c) Plan’s authority to sanction or
terminate a Provider found to be providing inadequate or poor quality care or failing to comply
with Plan’s systems, standards or procedures.
The Provider acknowledges and agrees that any delegation under a contract of quality assurance,
utilization management, credentialing, provider relations and other dental management programs,
shall be subject to Plan’s oversight and monitoring of DentaQuest’s performance. The Provider
further acknowledges and agrees that Plan, upon the failure of DentaQuest to properly implement
and administer such systems or to take prompt corrective action after identifying quality, member
satisfaction or other problems, may terminate the contract and that, as a result of such termination,
the Provider’s participation in Plan may also be terminated .
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7.
8.
9.
Independent Contractors
(a)
Professional Relationship. Provider is an independent contractor and is responsible for
maintaining a professional relationship with Members. Provider is responsible for his/her own acts
or omissions in his/her professional practice of dentistry, as well as those acts or omissions of
his/her employees and agents. No action by DentaQuest has or is intended to have the effect of
infringing upon Provider’s care and treatment of the Member, including without limitation all
decisions with respect to administration, treatment or discharge of such Member.
(b)
Appropriate Treatment. DentaQuest allows open Provider-Member communication regarding
appropriate treatment alternatives. Provider will not be penalized for discussing medically
necessary or appropriate patient care. A determination by DentaQuest that a particular course of
treatment is not a Covered Service does not relieve Provider from providing or recommending
such care to Members as he/she deems to be appropriate, and that determination may not be
considered to be a medical determination made by DentaQuest.
Provider Dentist
(a)
Provider Dentist Approval. Provider shall supply all information requested by DentaQuest for the
purpose of credentialing Provider Dentist, and Provider Dentist must be approved for participation
by DentaQuest in writing before rendering Covered Services to Members.
(b)
Rights and Obligations. Provider Dentist shall have the rights and obligations provided in the
Agreement which are applicable to Provider, and understands that certain provisions of the
Agreement shall also be individually binding on Provider Dentist, and that DentaQuest may
require performance of all provisions by Provider Dentist. Provider Dentist also understands that
DentaQuest and Provider may amend the Agreement without right of review by or approval of
Provider Dentist.
(c)
Reimbursement by Provider. Provider Dentist agrees to look solely to Provider for reimbursement
of Covered Services, where Provider is designated as payee pursuant to Agreement.
Term and Termination
(a)
Term. This Agreement shall begin on the Effective Date and shall end one (1) year from such
date. Thereafter, this agreement shall automatically renew for successive one (1) year periods
unless either party provides notice of its intent not to renew.
(b)
Termination. This Agreement may be terminated as follows:
i.
By DentaQuest upon 30 days prior written notice without cause.
ii.
By Provider upon 60 days prior written notice without cause.
iii.
By either party, in the event of a material breach of this Agreement by the other party,
upon 60 days prior written notice to the other party.
iv.
Upon the occurrence of any of the following events with respect to Provider, DentaQuest
has the option to immediately terminate Provider's designation as a Participating
Provider:
1.
the death of Provider;
2.
the loss or suspension of the dental license or Provider;
3.
the loss or suspension of Provider’s drug enforcement administration license, or
the loss of Provider’s unrestricted prescribing privileges;
4.
the loss of Provider’s liability insurance;
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5.
6.
7.
8.
9.
10.
11.
12.
(c)
10.
the Provider being restricted from receiving payments from Medicare or
Medicaid;
the Provider is convicted of any felony;
the Provider is convicted of any offense involving DentaQuest or Plan;
the failure of the Provider to meet any quality assurance, credentialing, or
grievance program requirements of DentaQuest, Plan or any state or federal
regulatory agency or their designees;
the Provider intentionally and purposefully does not comply with the referral
and notification requirements of DentaQuest, Plan or any state or federal
regulatory agency or their designees;
the Provider fails to cooperate with DentaQuest in the provision of costeffective, quality services to Members;
the Provider is found to be harming Members; or
any adverse regulatory finding with respect to Provider.
Effect of Termination. In the event of termination of this Agreement, Provider agrees to complete
any treatment in progress and/or assist in the orderly transfer of Members to another provider, as
requested by DentaQuest. Provider must provide timely notification to all Members affected by
Provider’s termination.
Miscellaneous
(a)
Non-exclusivity. This Agreement is not an exclusive contract and DentaQuest may contract with
other providers of dental services. Provider may contract with other dental plans. This Agreement
shall be regarded as confidential and its terms or contents shall not be disclosed to any other party
unless agreed to in writing by DentaQuest; except, however, Provider may disclose the contents of
this Agreement to the legal representative of Provider without the consent of DentaQuest.
(b)
Amendment or Restated Agreement. DentaQuest may amend or restate this Agreement by sending
a copy of the amendment or restated agreement to Provider at least 30 days prior to its effective
date. If Provider does not object to such amendment or restated agreement in writing within such
30-day notice period, Provider shall be deemed to have accepted the proposed amendment or
restated agreement as of the end of the 30-day notice period. In the event Provider objects within
the 30-day notice period, by providing written notice to DentaQuest, the parties shall confer in
good faith to reach agreement. If such agreement cannot be reached, DentaQuest may terminate
this Agreement.
(c)
Change in Status. Provider understands that any and all changes in the Provider's legal and
contractual relationship to and with Provider's clinic partners, who are also party to this
Agreement must be communicated in writing to DentaQuest, or DentaQuest may elect to
immediately terminate this Agreement. Provider also agrees to provide DentaQuest with 30 days
advance written notice of any closure of their practice to additional Members, or new location at
which Provider anticipates seeing Members.
(d)
Waiver of Breach. The waiver by either party of a breach of violation of any provision of the
Agreement shall not operate as or be construed to be a waiver of any subsequent breach hereof.
(e)
Governing Law. This Agreement shall be governed in all respects by the laws of the state of
Arizona.
(f)
Responsibility for Actions. Each party shall be responsible for any and all claims, liabilities,
damages, or judgments that may arise as a result of its own negligence or intentional wrongdoing.
(g)
Severability. The invalidity or unenforceability of any term of condition shall in no way affect the
validity or enforceability of the remainder of this Agreement.
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(h)
Arbitration. If a dispute regarding payment arises between the parties involving a contention by
one party that the other has failed to perform its obligations and responsibilities under this
Agreement, then the party making such contention shall promptly give notice to the other. Such
notice shall set forth in detail, the basis for the party’s contention, and shall be sent by Certified
Mail-Return Receipt Requested. The other party shall within thirty (30) calendar days of receipt
of the notice provide a written response seeking to satisfy the party that gave notice regarding the
matters as to which notice was given. Following such response, or the failure of the second party
to respond to the compliant of the first party within thirty (30) calendar days, if the party that gave
notice of dissatisfaction remains dissatisfied, then the party shall so notify the other party and the
matter shall be promptly submitted to inexpensive and binding arbitration.
(i)
Assignment. DentaQuest may assign this Agreement immediately upon written notice to
Provider. Provider must obtain DentaQuest’s prior written consent to assign this Agreement.
(j)
Notice. Any notices required to be given pursuant to the terms and provision hereof shall be sent
by mail, addressed to DentaQuest at:
DentaQuest of Arizona, LLC
Attn: Provider Information
12121 N. Corporate Parkway
Mequon, WI 53092
and to the Provider at the address stated herein or as he/she may otherwise notify DentaQuest in
writing.
(k)
Form. All words used herein in the singular number shall extend to and include the plural. All
words used in the plural numbers shall extend to and include the singular. All words used in any
gender shall extend to and include all genders.
(l)
Entire Agreement. This Agreement, together with all subordinate and other documents and
exhibits incorporated herein, constitutes the final and entire expression of the Agreement between
the parties with respect to the subject matter contained herein and expressly supercedes all prior
and contemporaneous representations, statements, drafts, correspondence or similar understanding
or documents.
121001 AZ Maricopa & UFC MA MC
10
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date written below:
Legal Entity Name & Address
Name
DentaQuest of Arizona, LLC
Yavapai County Community Health Services
Address 1090 Commerce Drive
Prescott, AZ 86301
Phone
(928) 442-5966
BY:
______________________________
(Signature)
BY:
Thomas Thurman, Chairman, BOS
(Please Print or Type Name)
BY: __________________________________
Steven J. Pollock
Chief Operating Officer
Tax ID# 86-6000561
Group NPI # 1659317022
DATE: _______/________/________
DATE: _______/________/________
PROVIDER DENTISTS
(Please Type or Print)
Please list the name of all individual dentists providing services under the terms of this Agreement.
Richard Zapfe
Dentist Name
General Practice
Specialty
Joonwoo Bae
Dentist Name
General Practice
Specialty
Mark Emshwiller
Dentist Name
General Practice
Specialty
Maritza Sanchez-Salazar
Dentist Name
General Practice
Specialty
________________________________
Dentist Name
_____________________________________
Specialty
________________________________
Dentist Name
_____________________________________
Specialty
121001 AZ Maricopa & UFC MA MC
11
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
12
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT A
DENTAQUEST OF ARIZONA, LLC
DENTAL PANEL REIMBURSEMENT
1.0
Provider Reimbursement
1.01
Maricopa Health Plan. Provider shall be paid the lesser of billed charges, or 100% of the fee
schedule attached hereto as Attachment A-1 for the provision of Medically Necessary Covered
Services as determined by DentaQuest to eligible Maricopa Health Plan Members. DentaQuest
does not permit or offer any financial incentives to Provider to encourage Provider to avoid
rendering Medically Necessary Covered Services to Members.
1.02
General and Pediatric Dentists in Maricopa County. Provider shall be paid the lesser of billed
charges, or 100% of the fee schedule attached hereto as Attachment A-2 for the provision of
Medically Necessary Services rendered to any eligible Plan Member which DentaQuest may
contract with utilizing the fee schedule Attachment A-2. Provider will be given 30 days advance
notice of any Plan/Members to which this fee schedule applies.
1.03
Specialists in Maricopa County. Provider shall be paid the lesser of billed charges, or 100% of the
fee schedule attached hereto as Attachment A-3 for the provision of Medically Necessary Services
rendered to any eligible Plan Member which DentaQuest may contract with utilizing the fee
schedule Attachment A-3. Provider will be given 30 days advance notice of any Plan/Members to
which this reimbursement arrangement applies.
1.04
General and Pediatric Dentists in Pima and Yavapai County. Provider shall be paid the lesser of
billed charges, or 100% of the fee schedule attached hereto as Attachment A-4 for the provision of
Medically Necessary Services rendered to any eligible Plan Member which DentaQuest may
contract with utilizing the fee schedule Attachment A-4. Provider will be given 30 days advance
notice of any Plan/Members to which this fee schedule applies.
1.05
Specialists in Pima and Yavapai County. Provider shall be paid the lesser of billed charges, or
100% of the fee schedule attached hereto as Attachment A-5 for the provision of Medically
Necessary Services rendered to any eligible Plan Member which DentaQuest may contract with
utilizing the fee schedule Attachment A-5. Provider will be given 30 days advance notice of any
Plan/Members to which this reimbursement arrangement applies.
2.0
Provider agrees to practice cost effective dentistry. Provider acknowledges that improper billing or the
rendering of dental care that is determined to be unnecessary or inappropriate by the DentaQuest Dental
Director, shall not be compensated and will constitute sufficient basis for termination of this agreement or
other measures as described in paragraph 3.0.
3.0
Provider acknowledges that “fee-for-service” dental reimbursement can only be maintained with the
cooperation and commitment of all dental panel members to practice cost effective, quality dentistry.
DentaQuest shall compile an internal “practice profile” for each member of the DentaQuest dental panel on
a periodic basis. This profile will compute averages for total cost per patient. Providers, whose practice
patterns deviate in a statistically significant way from the norms of the DentaQuest dental panel, may be
subject to notice of probationary status and/or possible termination, subject to the appropriate notice and
appeal procedures as stated herein.
4.0
DentaQuest shall pay Provider within thirty (30) calendar days of receipt of clean claims for dental services
rendered to Members. Provider agrees to accept electronic payment and electronic remittances if/when
available.
Provider reimbursement requires receipt of a clean claim. A claim shall be considered clean only if the
claim requires no further information, documentation, adjustment or alteration by Provider to be
adjudicated by DentaQuest. Any dispute regarding payment shall be deemed waived unless Provider
submits written notification of the reasons for the dispute within sixty (60) days of receipt of the payment,
statement of denial or adjustment.
121001 AZ Maricopa & UFC MA MC
A-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
A-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT A-1
DENTAQUEST OF ARIZONA, LLC
SCHEDULE OF ALLOWABLE FEES-MARICOPA HEALTH PLAN
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES **
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$23.77
D2794
crown - titanium
$322.37
D0140
limited oral evaluation
$31.44
D2910
recement inlay
$39.08
D0145
oral evaluation for patient under three
D2915
recement cast or prefabricated post and
years of age and counseling
$29.74
core
$39.08
D0150
comprehensive oral evaluation
$34.90
D2920
recement crown
$39.08
D0160
detailed and extensive oral evaluationD2930
prefab steel crown - prime tooth
$114.77
problem focused
$34.90
D2931
prefab steel crown - perm tooth
$133.47
D0180
comprehensive periodontal evaluation D2932
prefabricated resin crown
$113.08
new or established patient
$36.59
D2933
prefab steel crown w/resin win
$134.36
D0210
intraoral-comp (inc bitewings)
$62.05
D2934
prefab esthetic coated stainless steel
D0220
intraoral-periapical - 1st film
$12.73
crown-pr
$134.36
D0230
intraoral-periapical - each film
$10.23
D2940
sedative filling
$43.36
D0240
intraoral - occlusal film
$12.73
D2950
core buildup, including pins
$119.04
D0250
extraoral - first film
$14.43
D2951
pin retention - per tooth
$34.02
D0260
extraoral - each additional film
$11.05
D2952
cast post and core plus crown
$180.29
D0270
bitewing - single film
$10.23
D2954
prefab post & core
$112.83
D0272
bitewings - two films
$20.39
D2970
temporary crown (fracture)
$89.29
D0273
bitewings0three films
$25.55
D3110
pulp cap - direct
$16.12
D0274
bitewings - four films
$29.74
D3120
pulp cap - indirect
$16.12
D0277
vertical bitewings-7 to 8 films
$29.74
D3220
therapeutic pulpotomy
$68.90
D0290
skull and facial bone film
$31.44
D3221
gross pupal debridement, primary and
D0310
sialography
$49.72
permanent teeth
$68.90
D0320
temporomandibular joint arthrogram, incl
$97.76
D3230
pulpal therapy - anterior
$88.65
D0321
other TMJ films, by report
$46.74
D3240
pulpal therapy - posterior
$88.65
D0330
panoramic film
$52.72
D3310
anterior (exc final rest)
$314.64
D0340
cephalometric film
$45.05
D3320
bicuspid (exc final restore)
$380.08
D0350
oral/facial images (includes intra and
D3330
molar (excluding final restore)
$477.03
extraoral images)
$17.90
D3331
treatment of root canal obstruction; nonD0470
diagnostic casts
$44.25
surgical access
$88.41
D0502
other oral pathology procedures, by repo
$21.28
D3332
incomplete endodontic therapy;
D1110
prophylaxis - adult
$42.55
inoperable or fractured tooth
$181.10
D1120
prophylaxis - child
$36.59
D3333
internal root repair or perforation defects
$100.34
D1203
fluoride w/o prophy - child
$16.92
D3346
retreat prior root canal - anterior
$403.85
D1204
fluoride w/o prophy - adult
$16.92
D3347
retreat prior root canal - bicuspid
$425.13
D1206
topical fluoride varnish, theraputic appl
$16.92
D3348
retreatment root canal - molar
$505.88
D1310
nutritional counseling for control of
D3351
apexification/recalc - 1st visit
$75.69
dental disease
$21.68
D3352
apexification/recalcification
$63.75
D1351
sealant - per tooth
$22.97
D3353
apexification/recalcification
$204.06
D1510
space maintainer - fixed-uni
$126.69
D3410
apicoectomy/periradicular - ant
$289.09
D1515
space maintainer - fixed-bilateral
$181.10
D3421
apicoectomy surgery - bicuspid
$289.09
D1520
space maintainer - removable-uni
$126.69
D3425
apicoectomy surgery - molar 1st
$335.03
D1525
space maintainer - removable-bi
$181.10
D3426
apicoectomy surgery (each root)
$144.59
D1550
recementation space maintainer
$28.94
D3430
retrograde filling - per root
$101.15
D1555
removal of fixed space maintainer
$28.94
D3450
root amputation - per root
$166.67
D2140
amalgam - 1 surface, permanent
$62.05
D3470
intentional replantation
$363.08
D2150
amalgam - 2 surfaces, permanent
$74.79
D3920
hemisection
$166.67
D2160
amalgam - 3 surfaces, permanent
$90.11
D4210
gingivectomy - gingivoplast/quad
$231.31
D2161
amalgam - 4+ surfaces, permanent
$108.00
D4211
gingivectomy(plasty) per tooth
$90.88
D2330
resin - 1 surface, anterior, primary
$73.99
D4240
gingival flap w/root plan/quad
$263.63
D2331
resin - 2 surfaces, anterior
$93.57
D4241
gingival flap w/root plan 1-3/quad
$158.13
D2332
resin - 3 surfaces, anterior
$117.34
D4249
crown lengthening - hard tissue
$340.11
D2335
resin - 4+ surfaces, anterior
$141.11
D4260
osseous surgery - per quadrant
$421.74
D2390
composite crown – anterior
$170.05
D4261
osseous surgery –1-3 teeth/quad
$275.47
D2391
composite - 1 surface, post- permanent
$62.05
D4263
bone replacement graft; first site in
D2392
composite - 2 surfaces, post- permanent
$74.79
quadrant
$233.80
D2393
composite – 3 surfaces, post-permanent
$90.11
D4264
bone replacement graft; each additional
D2394
composite – 4+ surfaces, post-primary
$108.00
site in quadrant
$221.07
D2712
crown-3/4 resin based composite-indirect
$178.08
D4265
biologic material to aid in soft and
D2750
crown - porce fused to high noble
$483.81
osseous tissue regeneration
$250.81
D2751
crown - porcelain fused to metal
$483.81
D4266
guided tissue regeneration; resorbable
D2752
crown - porce fused to noble metal
$483.81
barrier; per site
$240.65
D2790
crown - full cast high noble
$483.81
D4267
guided tissue regeneration; nonD2791
crown - full cast base metal
$483.81
resorbable barrier; per site
$259.35
D2792
crown - full cast noble metal
$483.81
D4270
pedicle soft tissue graft proc
$258.47
121001 AZ Maricopa & UFC MA MC
A-1-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5811
D5820
D5821
D5850
D5851
D5862
D6930
D7110
D7111
D7120
D7130
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
Description
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site surgery)
distal or proximal wedge procedure
(when not performed in conjunction with
surgical procedures in the same
anatomical area)
soft tissue allograft
combined connective tissue and double
pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3 teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim comp dent - mandibular
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
precision attachment by report
recement fixed partial denture
extraction single tooth
coronal remnants-primary tooth
extraction each additional tooth
root removal-exposed roots
extraction – erupted tooth/exposed root
surgical removal erupted tooth
removal impacted tooth - soft
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
surg remove residual roots
oroantral fistula closure
Fee
$307.79
$437.86
Code
D7261
D7270
D7280
D7281
D7282
$271.20
$340.98
$442.14
$149.66
$114.77
$123.31
$73.10
$63.75
$61.26
$25.55
$627.50
$627.50
$703.99
$703.99
$586.72
$586.72
$688.74
$688.74
$306.09
$34.02
$34.02
$34.02
$34.02
$90.11
$68.90
$62.94
$72.30
$73.99
$68.90
$81.64
$108.80
$261.85
$261.85
$261.85
$261.85
$144.59
$144.59
$132.65
$132.65
$202.37
$202.37
$171.74
$171.74
$322.78
$289.09
$289.09
$72.30
$72.30
$14.80
$39.08
$60.70
$48.36
$54.00
$70.63
$70.92
$108.80
$133.47
$170.05
$199.00
$246.62
$108.80
$255.08
D7283
D7285
D7286
D7290
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
Description
primary closure of a sinus perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or unerupted
tooth
mobilization of erupted or malpositioned
tooth to aid eruption
placement of device to facilitate eruption
of impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
surgical reposition of teeth
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or tooth
spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion – 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion, complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion, complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25 cm
removal nonodontogenic cyst->1.25 cm
destruction of lesion(s) by physical or
chemical method
removal of lateral exotosis-(maxilla of
mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscess-intraoral
soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscess-extraoral
soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction – immobilized
max- closed reduction – immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch –open reduction
malar/zygo arch –closed reduction
alveolus-closed reduction
alveolus- open reduction
facial bones-complicated reduction
max-open reduction-compound
max-closed reduction – compound
mand – open reduction-compound
mand- closed reduction-compound
malar/zygo-open reduction- compound
malar/zygo-closed reduction-compound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
open reduction-dislocation
closed reduction-dislocation
121001 AZ Maricopa & UFC MA MC
A-1-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$255.08
$246.62
$183.67
$110.57
$110.57
$45.05
$130.10
$130.07
$124.96
$129.28
$81.64
$170.05
$113.08
$90.11
$199.79
$233.80
$178.60
$263.63
$276.36
$174.32
$259.35
$129.28
$165.78
$94.37
$124.93
$60.45
$201.49
$282.07
$443.26
$229.69
$2,780.47
$60.45
$201.49
$108.80
$221.64
$74.96
$92.69
$153.13
$294.42
$1,410.38
$1,007.42
$1,718.26
$886.53
$1,007.42
$685.05
$276.44
$1,390.24
$2,296.91
$1,571.57
$963.09
$1,652.16
$1,039.65
$1,511.13
$1,043.69
$1,007.42
$584.31
$2,893.30
$1,442.62
$124.93
Code
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670
Description
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or without
biopsy
arthroscopy-surgical: lavage and lysis o
arthroscopy-surgical: disc repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with bone
graft, includes obtaining the graft
osteotomy-segmented or subapical-per
sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal, or
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous tuberosity
sialolithotomy
excision of salivary gland-by report
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
limited orthodontic treatment or the
adolescent dentition
limited orthodontic treatment or the adult
dentition
interceptive orthodontic treatment of the
primary dentition
interceptive orthodontic treatment of the
transitional dentition
comprehensive orthodontic treatment of
the transitional dentition
comprehensive orthodontic treatment of
the adolescent dentition
comprehensive orthodontic treatment of
the adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
periodic orthodontic treatment visit
Fee
$189.40
$1,833.50
$1,672.31
$2,087.37
$1,094.46
$2,189.72
$431.18
$2,189.72
$132.98
$241.78
$374.77
$979.21
$979.21
$1,323.34
$1,323.34
$2,189.72
$268.38
$200.68
$56.41
$95.12
$221.64
$1,007.42
$2,780.47
$2,780.47
$2,333.18
$2,518.55
$2,812.70
$2,574.96
$3,222.92
$3,344.62
$721.32
$729.37
$117.67
$117.67
$122.50
$59.64
$100.75
$157.16
$608.48
$443.26
$165.22
$294.17
$1,027.57
Code
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
D9920
D9930
D9940
D9951
Description
orthodontic retention (removal of
appliances, construction, and placement
of retainers)
orthodontic treatment (alternative billing
to contracted fee)
replacement of lost or broken retainer
rebonding or recementing and/or repair of
fixed retainer
palliative treatment
fixed partial denture sectioning
local anesthesia w/o operative or surgical
procedure
deep sedation/general anesthesia - 1st 30
min
deep sedation/general anesthesia - each
15 min
analgesia/anxiolysis/inhalation of nitrous
oxide
iv conscious sedation/analgesia - 1st 30
min
iv conscious sedation/analgesia - each 15
min
non-intravenous conscious
sedation/analgesia
consultation
house/extended care facility call
hospital call
office visit for observation
office visit after regularly scheduled
hours
therapeutic drug injection - by report
therapeutic parenteral drugs 2 +
administrations, different medications
behavior management - by report
treatment of complications - post surgical
- by report
occlusal guard - by report
occlusal adjustment - limited
$238.08
$238.08
$238.08
$238.08
$1,105.33
$1,105.33
$2,210.68
$2,486.13
$2,572.87
$259.35
$284.82
$38.29
$112.26
121001 AZ Maricopa & UFC MA MC
A-1-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$170.05
$55.29
$110.57
$39.08
$48.44
$44.25
$8.54
$117.67
$54.80
$21.28
$113.08
$32.32
$51.02
$33.13
$38.29
$68.02
$23.77
$53.59
$16.12
$25.55
$29.74
$23.77
$153.05
$41.67
ATTACHMENT A-2
DENTAQUEST OF ARIZONA, LLC
SCHEDULE OF ALLOWABLE FEES-GENERAL AND PEDIATRIC DENTISTS-MARICOPA COUNTY
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES **
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$23.60
D2751
crown - porcelain fused to metal
$480.24
D0140
limited oral evaluation
$31.20
D2752
crown - porce fused to noble metal
$480.24
D0145
oral evaluation for patient under
$29.52
D2790
crown - full cast high noble
$480.24
three years of age and counseling
D2791
crown - full cast base metal
$480.24
D0150
comprehensive oral evaluation
$34.64
D2792
crown - full cast noble metal
$480.24
D0160
detailed and extensive oral
$34.64
D2794
crown - titanium
$320.00
evaluation-problem focused
D2910
recement inlay
$38.80
D0180
comprehensive periodontal
$36.32
D2915
recement cast or prefabricated post
$38.80
evaluation - new or established
and core
patient
D2920
recement crown
$38.80
D0210
intraoral-comp (inc bitewings)
$61.61
D2930
prefab steel crown - prime tooth
$113.92
D0220
intraoral-periapical - 1st film
$12.64
D2931
prefab steel crown - perm tooth
$132.48
D0230
intraoral-periapical - each film
$10.16
D2932
prefabricated resin crown
$112.24
D0240
intraoral - occlusal film
$12.64
D2933
prefab steel crown w/resin win
$133.36
D0250
extraoral - first film
$14.32
D2934
prefab esthetic coated stainless steel
$133.36
D0260
extraoral - each additional film
$10.96
crown-pr
D0270
bitewing - single film
$10.16
D2940
sedative filling
$43.04
D0272
bitewings - two films
$20.24
D2950
core buildup, including pins
$118.16
D0273
bitewings0three films
$25.36
D2951
pin retention - per tooth
$33.76
D0274
bitewings - four films
$29.52
D2952
cast post and core plus crown
$178.96
D0277
vertical bitewings-7 to 8 films
$29.52
D2970
temporary crown (fracture)
$88.64
D0290
skull and facial bone film
$31.20
D3110
pulp cap - direct
$16.00
D0310
$44.00
D3120
pulp cap - indirect
$16.00
sialography
D0320
temporomandibular joint arthrogram,
$97.04
D3220
therapeutic pulpotomy
$68.40
incl
D3221
gross pupal debridement, primary
$68.40
D0321
other TMJ films, by report
$46.40
and permanent teeth
D0330
panoramic film
$52.32
D3230
pulpal therapy - anterior
$88.00
D0340
cephalometric film
$44.72
D3240
pulpal therapy - posterior
$88.00
D0350
oral/facial images (includes intra and
$17.76
D3310
anterior (exc final rest)
$312.32
extraoral images)
D3320
bicuspid (exc final restore)
$377.28
D0470
diagnostic casts
$43.92
D3330
molar (excluding final restore)
$473.52
D0502
other oral pathology procedures, by
$21.12
D3331
treatment of root canal obstruction;
$87.76
repo
non-surgical access
D1110
prophylaxis - adult
$42.24
D3332
incomplete endodontic therapy;
$179.76
D1120
prophylaxis - child
$36.32
inoperable or fractured tooth
D1203
fluoride w/o prophy - child
$16.80
D3333
internal root repair or perforation
$99.60
D1204
fluoride w/o prophy - adult
$16.80
defects
D1206
topical fluoride varnish, theraputic
$16.80
D3346
retreat prior root canal - anterior
$400.88
appl
D3347
retreat prior root canal - bicuspid
$422.00
D1351
sealant - per tooth
$22.80
D3348
retreatment root canal - molar
$502.16
D1510
space maintainer - fixed-uni
$125.76
D3351
apexification/recalc - 1st visit
$75.12
D1515
space maintainer - fixed-bilateral
$179.76
D3352
apexification/recalcification
$63.28
D1520
space maintainer - removable-uni
$125.76
D3353
apexification/recalcification
$202.56
D1525
space maintainer - removable-bi
$179.76
D3410
apicoectomy/periradicular - ant
$286.96
D1550
recementation space maintainer
$28.72
D3421
apicoectomy surgery - bicuspid
$286.96
D1555
removal of fixed space maintainer
$28.72
D3425
apicoectomy surgery - molar 1st
$332.56
D2140
amalgam - 1 surface, permanent
$61.60
D3426
apicoectomy surgery (each root)
$143.52
D2150
amalgam - 2 surfaces, permanent
$74.24
D3430
retrograde filling - per root
$100.40
D2160
amalgam - 3 surfaces, permanent
$89.44
D3450
root amputation - per root
$165.44
D2161
amalgam - 4+ surfaces, permanent
$107.20
D3470
intentional replantation
$360.40
D2330
resin - 1 surface, anterior, primary
$73.44
D3920
hemisection
$165.44
D2331
resin - 2 surfaces, anterior
$92.88
D4210
gingivectomy - gingivoplast/quad
$229.60
D2332
resin - 3 surfaces, anterior
$116.48
D4211
gingivectomy(plasty) per tooth
$89.44
D2335
resin - 4+ surfaces, anterior
$140.08
D4240
gingival flap w/root plan/quad
$261.68
D2390
composite crown – anterior
$168.80
D4241
gingival flap w/root plan 1-3/quad
$156.96
D2391
composite - 1 surface, post$61.60
D4249
crown lengthening - hard tissue
$337.60
permanent
D4260
osseous surgery - per quadrant
$418.64
D2392
composite - 2 surfaces, post$74.24
D4261
osseous surgery –1-3 teeth/quad
$273.44
permanent
D4263
bone replacement graft; first site in
$232.08
D2393
composite – 3 surfaces, post$89.44
quadrant
permanent
D4264
bone replacement graft; each
$219.44
D2394
composite – 4+ surfaces, post$107.20
additional site in quadrant
primary
D4265
biologic material to aid in soft and
$248.96
D2750
crown - porce fused to high noble
$480.24
osseous tissue regeneration
121001 AZ Maricopa & UFC MA MC
A-2-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4266
D4267
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D6930
D7111
D7140
D7210
D7220
Description
guided tissue regeneration;
resorbable barrier; per site
guided tissue regeneration; nonresorbable barrier; per site
pedicle soft tissue graft proc
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site
surgery)
distal or proximal wedge procedure
(when not performed in conjunction
with surgical procedures in the same
anatomical area)
soft tissue allograft
combined connective tissue and
double pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3
teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
recement fixed partial denture
coronal remnants-primary tooth
extraction – erupted tooth/exposed
root
surgical removal erupted tooth
removal impacted tooth - soft
Fee
$238.88
$257.44
$256.56
$305.52
$434.64
$269.20
Code
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7280
D7281
D7282
$338.48
$438.88
$148.56
$113.92
$122.40
$72.56
$63.28
$60.80
$25.36
$622.88
$622.88
$698.80
$698.80
$582.40
$582.40
$683.68
$683.68
$303.84
$33.76
$33.76
$33.76
$33.76
$89.44
$68.40
$62.48
$71.76
$73.44
$68.40
$81.04
$108.00
$259.92
$259.92
$259.92
$259.92
$143.52
$143.52
$131.68
$131.68
$200.88
$200.88
$170.48
$170.48
$286.96
$286.96
$71.76
$71.76
$38.80
$48.00
$70.40
$108.00
$132.48
D7283
D7285
D7286
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
Description
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
surg remove residual roots
oroantral fistula closure
primary closure of a sinus
perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or
unerupted tooth
mobilization of erupted or
malpositioned tooth to aid eruption
placement of device to facilitate
eruption of impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or
tooth spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion – 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion,
complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion,
complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25
cm
removal nonodontogenic cyst->1.25
cm
destruction of lesion(s) by physical
or chemical method
removal of lateral exotosis-(maxilla
of mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous
tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscessintraoral soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscessextraoral soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction – immobilized
max- closed reduction – immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch –open reduction
malar/zygo arch –closed reduction
alveolus-closed reduction
alveolus- open reduction
facial bones-complicated reduction
max-open reduction-compound
121001 AZ Maricopa & UFC MA MC
A-2-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$168.80
$197.52
$244.80
$108.00
$253.20
$253.20
$244.80
$182.32
$109.76
$109.76
$44.72
$129.12
$129.12
$128.32
$81.04
$168.80
$112.24
$89.44
$198.32
$232.08
$177.28
$261.68
$274.32
$173.04
$257.44
$128.32
$164.56
$93.68
$124.00
$60.00
$200.00
$280.00
$440.00
$228.00
$2,760.00
$60.00
$200.00
$108.00
$220.00
$74.40
$92.00
$152.00
$292.00
$1,400.00
$1,000.00
$1,705.60
$880.00
$1,000.00
$680.00
$274.40
$1,380.00
$2,280.00
$1,560.00
Code
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
Description
max-closed reduction – compound
mand – open reduction-compound
mand- closed reduction-compound
malar/zygo-open reductioncompound
malar/zygo-closed reductioncompound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
open reduction-dislocation
closed reduction-dislocation
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or
without biopsy
arthroscopy-surgical: lavage and
lysis o
arthroscopy-surgical: disc
repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with
bone graft, includes obtaining the
graft
osteotomy-segmented or subapicalper sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal,
or
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous
tuberosity
sialolithotomy
Fee
$956.00
$1,640.00
$1,032.00
$1,500.00
$1,036.00
$1,00.00
$580.00
$2,872.00
$1,432.00
$124.00
$188.00
$1,820.00
$1,660.00
$2,072.00
$1,086.40
$2,173.60
$428.00
$2,173.60
$132.00
$240.00
$372.00
$972.00
$972.00
$1,313.60
$1,313.60
$2,173.60
$266.40
$199.20
$56.00
$94.40
$220.00
$1,000.00
$2,760.00
$2,760.00
$2,316.00
$2,500.00
$2,792.00
$2,556.00
$3,199.20
$3,320.00
$716.00
$724.00
$116.80
$116.80
$121.60
$59.20
$100.00
$156.00
Code
D7981
D7982
D7983
D7990
D7991
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
D9920
D9930
D9940
D9951
Description
excision of salivary gland-by report
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
limited orthodontic treatment or the
adolescent dentition
limited orthodontic treatment or the
adult dentition
interceptive orthodontic treatment of
the primary dentition
interceptive orthodontic treatment of
the transitional dentition
comprehensive orthodontic treatment
of the transitional dentition
comprehensive orthodontic treatment
of the adolescent dentition
comprehensive orthodontic treatment
of the adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
periodic orthodontic treatment visit
orthodontic retention (removal of
appliances, construction, and
placement of retainers)
orthodontic treatment (alternative
billing to contracted fee)
replacement of lost or broken
retainer
rebonding or recementing and/or
repair of fixed retainer
palliative (emergency) treat
fixed partial denture sectioning
local anesthesia non-surgical
gen anesthesia - first 30 minutes
gen anesthesia – each add’l 15 min
analgesia
intravenous conscious
sedation/analgesia; first 30 minutes
intravenous conscious
sedation/analgesia; each additional
15 minutes
non-intavenous conscious sedation
consultation
house call
hospital call
office visit for observation
office visit - after hours
therapeutic drug injection
theraputic parenteral drugs
behavior management-by report
treat complication (post-surg)
occlusal guard – by report
occlusal adjustment –limited
121001 AZ Maricopa & UFC MA MC
A-2-3
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$604.00
$440.00
$164.00
$292.00
$1,020.00
$236.32
$236.32
$236.32
$236.32
$1,097.20
$1,097.20
$2,194.40
$2,467.84
$2,553.92
$257.44
$282.72
$38.00
$111.44
$168.80
$54.88
$109.76
$38.80
$48.08
$43.92
$8.48
$116.80
$54.40
$21.12
$112.24
$32.08
$50.64
$32.88
$38.00
$67.52
$23.60
$53.20
$16.00
$25.36
$29.52
$23.60
$151.92
$41.36
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
A-2-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT A-3
DENTAQUEST OF ARIZONA, LLC
SCHEDULE OF ALLOWABLE FEES-SPECIALISTS-MARICOPA COUNTY
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES **
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$27.73
D2790
crown - full cast high noble
$564.28
D0140
limited oral evaluation
$36.66
D2791
crown - full cast base metal
$564.28
D0145
oral evaluation for patient under three
$34.69
D2792
crown - full cast noble metal
$564.28
years of age and counseling
D2794
crown - titanium
$376.00
D0150
comprehensive oral evaluation
$40.70
D2910
recement inlay
$45.59
D0160
detailed and extensive oral evaluation$40.70
D2915
recement cast or prefabricated post and
$45.59
problem focused
core
D0180
comprehensive periodontal evaluation
$42.68
D2920
recement crown
$45.59
- new or established patient
D2930
prefab steel crown - prime tooth
$133.86
D0210
intraoral-comp (inc bitewings)
$72.38
D2931
prefab steel crown - perm tooth
$155.66
D0220
intraoral-periapical - 1st film
$14.85
D2932
prefabricated resin crown
$131.88
D0230
intraoral-periapical - each film
$11.94
D2933
prefab steel crown w/resin win
$156.70
D0240
intraoral - occlusal film
$14.85
D2934
prefab esthetic coated stainless steel
$156.70
D0250
extraoral - first film
$16.83
crown-pr
D0260
extraoral - each additional film
$12.88
D2940
sedative filling
$50.57
D0270
bitewing - single film
$11.94
D2950
core buildup, including pins
$138.84
D0272
bitewings - two films
$23.78
D2951
pin retention - per tooth
$39.67
D0273
bitewings0three films
$29.80
D2952
cast post and core plus crown
$210.28
D0274
bitewings - four films
$34.69
D2970
temporary crown (fracture)
$104.15
D0277
vertical bitewings-7 to 8 films
$34.69
D3110
pulp cap - direct
$18.80
D0290
skull and facial bone film
$36.66
D3120
pulp cap - indirect
$18.80
D0310
$52.25
D3220
therapeutic pulpotomy
$80.37
sialography
D0320
temporomandibular joint arthrogram,
$114.02
D3221
gross pupal debridement, primary and
$80.37
incl
permanent teeth
D0321
other TMJ films, by report
$54.52
D3230
pulpal therapy - anterior
$103.40
D0330
panoramic film
$61.48
D3240
pulpal therapy - posterior
$103.40
D0340
cephalometric film
$52.55
D3310
anterior (exc final rest)
$366.98
D0350
oral/facial images (includes intra and
$20.87
D3320
bicuspid (exc final restore)
$443.30
extraoral images)
D3330
molar (excluding final restore)
$556.39
D0470
diagnostic casts
$51.61
D3331
treatment of root canal obstruction;
$103.12
D0502
other oral pathology procedures, by
$24.82
non-surgical access
repo
D3332
incomplete endodontic therapy;
$211.22
D1110
prophylaxis - adult
$49.63
inoperable or fractured tooth
D1120
prophylaxis - child
$42.68
D3333
internal root repair or perforation
$117.03
D1203
fluoride w/o prophy - child
$19.74
defects
D1204
fluoride w/o prophy - adult
$19.74
D3346
retreat prior root canal - anterior
$471.03
D1206
topical fluoride varnish, theraputic appl
$19.74
D3347
retreat prior root canal - bicuspid
$495.85
D1351
sealant - per tooth
$26.79
D3348
retreatment root canal - molar
$590.04
D1510
space maintainer - fixed-uni
$147.77
D3351
apexification/recalc - 1st visit
$88.27
D1515
space maintainer - fixed-bilateral
$211.22
D3352
apexification/recalcification
$74.35
D1520
space maintainer - removable-uni
$147.77
D3353
apexification/recalcification
$238.01
D1525
space maintainer - removable-bi
$211.22
D3410
apicoectomy/periradicular - ant
$337.18
D1550
recementation space maintainer
$33.75
D3421
apicoectomy surgery - bicuspid
$337.18
D1555
removal of fixed space maintainer
$33.75
D3425
apicoectomy surgery - molar 1st
$390.76
D2140
amalgam - 1 surface, permanent
$72.38
D3426
apicoectomy surgery (each root)
$168.64
D2150
amalgam - 2 surfaces, permanent
$87.23
D3430
retrograde filling - per root
$117.97
D2160
amalgam - 3 surfaces, permanent
$105.09
D3450
root amputation - per root
$194.39
D2161
amalgam - 4+ surfaces, permanent
$125.96
D3470
intentional replantation
$423.47
D2330
resin - 1 surface, anterior, primary
$86.29
D3920
hemisection
$194.39
D2331
resin - 2 surfaces, anterior
$109.13
D4210
gingivectomy - gingivoplast/quad
$269.78
D2332
resin - 3 surfaces, anterior
$136.86
D4211
gingivectomy(plasty) per tooth
$105.09
D2335
resin - 4+ surfaces, anterior
$164.59
D4240
gingival flap w/root plan/quad
$307.47
D2390
composite crown - anterior
$198.34
D4241
gingival flap w/root plan 1-3/quad
$184.43
D2391
composite - 1 surface, post- permanent
$72.38
D4249
crown lengthening - hard tissue
$396.68
D2392
composite - 2 surfaces, post$87.23
D4260
osseous surgery - per quadrant
$491.90
permanent
D4261
osseous surgery -1-3 teeth/quad
$321.29
D2393
composite - 3 surfaces, post-permanent
$105.09
D4263
bone replacement graft; first site in
$272.69
D2394
composite - 4+ surfaces, post-primary
$125.96
quadrant
D2750
crown - porce fused to high noble
$564.28
D4264
bone replacement graft; each
$257.84
D2751
crown - porcelain fused to metal
$564.28
additional site in quadrant
D2752
crown - porce fused to noble metal
$564.28
D4265
biologic material to aid in soft and
$292.53
osseous tissue regeneration
D4266
guided tissue regeneration; resorbable
$280.68
barrier; per site
121001 AZ Maricopa & UFC MA MC
A-3-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4267
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D6930
D7111
D7140
D7210
D7220
D7230
D7240
D7241
Description
guided tissue regeneration; nonresorbable barrier; per site
pedicle soft tissue graft proc
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site
surgery)
distal or proximal wedge procedure
(when not performed in conjunction
with surgical procedures in the same
anatomical area)
soft tissue allograft
combined connective tissue and
double pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3
teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
recement fixed partial denture
coronal remnants-primary tooth
extraction - erupted tooth/exposed
root
surgical removal erupted tooth
removal impacted tooth - soft
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
Fee
$302.49
$301.46
$358.99
$510.70
$316.31
Code
D7250
D7260
D7261
D7270
D7280
D7281
D7282
D7283
$397.71
$515.68
$174.56
$133.86
$143.82
$85.26
$74.35
$71.44
$29.80
$731.88
$731.88
$821.09
$821.09
$684.32
$684.32
$803.32
$803.32
$357.01
$39.67
$39.67
$39.67
$39.67
$105.09
$80.37
$73.41
$84.32
$86.29
$80.37
$95.22
$126.90
$305.41
$305.41
$305.41
$305.41
$168.64
$168.64
$154.72
$154.72
$236.03
$236.03
$200.31
$200.31
$337.18
$337.18
$84.32
$84.32
$45.59
$56.40
$82.72
$126.90
$155.66
$198.34
$232.09
$287.64
D7285
D7286
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
Description
surg remove residual roots
oroantral fistula closure
primary closure of a sinus perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or
unerupted tooth
mobilization of erupted or
malpositioned tooth to aid eruption
placement of device to facilitate
eruption of impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or
tooth spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion - 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion,
complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion,
complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25
cm
removal nonodontogenic cyst->1.25
cm
destruction of lesion(s) by physical or
chemical method
removal of lateral exotosis-(maxilla
of mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous
tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscessintraoral soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscessextraoral soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction - immobilized
max- closed reduction - immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch -open reduction
malar/zygo arch -closed reduction
alveolus-closed reduction
alveolus- open reduction
facial bones-complicated reduction
max-open reduction-compound
max-closed reduction - compound
mand - open reduction-compound
mand- closed reduction-compound
121001 AZ Maricopa & UFC MA MC
A-3-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$126.90
$297.51
$297.51
$287.64
$214.23
$128.97
$128.97
$52.55
$151.75
$151.72
$150.78
$95.22
$198.34
$131.88
$105.09
$233.03
$272.69
$208.30
$307.47
$322.33
$203.32
$302.49
$150.78
$193.36
$110.07
$145.70
$70.50
$235.00
$329.00
$517.00
$267.90
$3,243.00
$70.50
$235.00
$126.90
$258.50
$87.42
$108.10
$178.60
$343.10
$1,645.00
$1,175.00
$2,004.08
$1,034.00
$1,175.00
$799.00
$322.42
$1,621.50
$2,679.00
$1,833.00
$1,123.30
$1,927.00
$1,212.60
Code
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
Description
malar/zygo-open reductioncompound
malar/zygo-closed reductioncompound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
open reduction-dislocation
closed reduction-dislocation
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or
without biopsy
arthroscopy-surgical: lavage and lysis
o
arthroscopy-surgical: disc
repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with
bone graft, includes obtaining the
graft
osteotomy-segmented or subapicalper sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal,
or
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous
tuberosity
sialolithotomy
excision of salivary gland-by report
Fee
$1,762.50
$1,217.30
$1,175.00
$681.50
$3,374.60
$1,682.60
$145.70
$220.90
$2,138.50
$1,950.50
$2,434.60
$1,276.52
$2,553.98
$502.90
$2,553.98
$155.10
$282.00
$437.10
Code
D7982
D7983
D7990
D7991
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
$1,142.10
$1,142.10
$1,543.48
$1,543.48
$2,553.98
$313.02
$234.06
$65.80
$110.95
$258.50
$1,175.00
$3,243.00
$3,243.00
$2,721.30
$2,937.50
$3,280.60
$3,003.30
$3,759.06
$3,901.00
$841.30
$850.70
$137.24
$137.24
$142.88
$69.56
$117.50
$183.30
$709.70
D8210
D8220
D8660
D8670
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
D9920
D9930
D9940
D9951
Description
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
limited orthodontic treatment or the
adolescent dentition
limited orthodontic treatment or the
adult dentition
interceptive orthodontic treatment of
the primary dentition
interceptive orthodontic treatment of
the transitional dentition
comprehensive orthodontic treatment
of the transitional dentition
comprehensive orthodontic treatment
of the adolescent dentition
comprehensive orthodontic treatment
of the adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
periodic orthodontic treatment visit
orthodontic retention (removal of
appliances, construction, and
placement of retainers)
orthodontic treatment (alternative
billing to contracted fee)
replacement of lost or broken retainer
rebonding or recementing and/or
repair of fixed retainer
palliative (emergency) treat
fixed partial denture sectioning
local anesthesia non-surgical
gen anesthesia - first 30 minutes
gen anesthesia - each add'l 15 min
analgesia
intravenous conscious
sedation/analgesia; first 30 minutes
intravenous conscious
sedation/analgesia; each additional 15
minutes
non-intavenous conscious sedation
consultation
house call
hospital call
office visit for observation
office visit - after hours
therapeutic drug injection
theraputic parenteral drugs
behavior management-by report
treat complication (post-surg)
occlusal guard - by report
occlusal adjustment -limited
121001 AZ Maricopa & UFC MA MC
A-3-3
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$517.00
$192.70
$343.10
$1,198.50
$277.68
$277.68
$277.68
$277.68
$1,289.21
$1,289.21
$2,578.42
$2,899.71
$3,000.86
$302.49
$332.20
$44.65
$130.94
$198.34
$64.48
$128.97
$45.59
$56.49
$51.61
$9.96
$137.24
$63.92
$24.82
$131.88
$37.69
$59.50
$38.63
$44.65
$79.34
$27.73
$62.51
$18.80
$29.80
$34.69
$27.73
$178.51
$48.60
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
A-3-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT A-4
DENTAQUEST OF ARIZONA, LLC
SCHEDULE OF ALLOWABLE FEES-GENERAL AND PEDIATRIC DENTISTS-PIMA & YAVAPAI COUNTY
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES **
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$26.55
D2792
crown - full cast noble metal
$540.27
D0140
limited oral evaluation
$35.10
D2794
crown - titanium
$360.00
D0145
oral evaluation for patient under three
$33.21
D2910
recement inlay
$43.65
years of age and counseling
D2915
recement cast or prefabricated post and
$43.65
D0150
comprehensive oral evaluation
$38.97
core
D0160
detailed and extensive oral evaluation$38.97
D2920
recement crown
$43.65
problem focused
D2930
prefab steel crown - prime tooth
$128.16
D0180
comprehensive periodontal evaluation $40.86
D2931
prefab steel crown - perm tooth
$149.04
new or established patient
D2932
prefabricated resin crown
$126.27
D0210
intraoral-comp (inc bitewings)
$69.30
D2933
prefab steel crown w/resin win
$150.03
D0220
intraoral-periapical - 1st film
$14.22
D2934
prefab esthetic coated stainless steel
$150.03
D0230
intraoral-periapical - each film
$11.43
crown-pr
D0240
intraoral - occlusal film
$14.22
D2940
sedative filling
$48.42
D0250
extraoral - first film
$16.11
D2950
core buildup, including pins
$132.93
D0260
extraoral - each additional film
$12.33
D2951
pin retention - per tooth
$37.98
D0270
bitewing - single film
$11.43
D2952
cast post and core plus crown
$201.33
D0272
bitewings - two films
$22.77
D2954
prefab post & core
$134.00
D0273
bitewings0three films
$28.53
D2970
temporary crown (fracture)
$99.72
D0274
bitewings - four films
$32.21
D3110
pulp cap - direct
$18.00
D0277
vertical bitewings-7 to 8 films
$32.21
D3120
pulp cap - indirect
$18.00
D0290
skull and facial bone film
$35.10
D3220
therapeutic pulpotomy
$76.95
D0310
$49.50
D3221
gross pupal debridement, primary and
$76.95
sialography
D0320
temporomandibular joint arthrogram,
$109.17
permanent teeth
incl
D3230
pulpal therapy - anterior
$99.00
D0321
other TMJ films, by report
$52.20
D3240
pulpal therapy - posterior
$99.00
D0330
panoramic film
$58.86
D3310
anterior (exc final rest)
$351.36
D0340
cephalometric film
$50.31
D3320
bicuspid (exc final restore)
$424.44
D0350
oral/facial images (includes intra and
$19.98
D3330
molar (excluding final restore)
$532.71
extraoral images)
D3331
treatment of root canal obstruction;
$98.73
D0470
diagnostic casts
$49.41
non-surgical access
D0502
other oral pathology procedures, by
$23.76
D3332
incomplete endodontic therapy;
$202.23
repo
inoperable or fractured tooth
D1110
prophylaxis - adult
$47.52
D3333
internal root repair or perforation
$112.05
D1120
prophylaxis - child
$40.86
defects
D1203
fluoride w/o prophy - child
$18.90
D3346
retreat prior root canal - anterior
$450.99
D1204
fluoride w/o prophy - adult
$18.90
D3347
retreat prior root canal - bicuspid
$474.75
D1206
topical fluoride varnish, theraputic appl
$18.90
D3348
retreatment root canal - molar
$564.93
D1351
sealant - per tooth
$25.65
D3351
apexification/recalc - 1st visit
$84.51
D1510
space maintainer - fixed-uni
$141.48
D3352
apexification/recalcification
$71.19
D1515
space maintainer - fixed-bilateral
$202.23
D3353
apexification/recalcification
$227.88
D1520
space maintainer - removable-uni
$141.48
D3410
apicoectomy/periradicular - ant
$322.83
D1525
space maintainer - removable-bi
$202.23
D3421
apicoectomy surgery - bicuspid
$322.83
D1550
recementation space maintainer
$32.31
D3425
apicoectomy surgery - molar 1st
$374.13
D1555
removal of fixed space maintainer
$32.31
D3426
apicoectomy surgery (each root)
$161.46
D2140
amalgam - 1 surface, permanent
$69.30
D3430
retrograde filling - per root
$112.95
D2150
amalgam - 2 surfaces, permanent
$83.52
D3450
root amputation - per root
$186.12
D2160
amalgam - 3 surfaces, permanent
$100.62
D3470
intentional replantation
$405.45
D2161
amalgam - 4+ surfaces, permanent
$120.60
D3920
hemisection
$186.12
D2330
resin - 1 surface, anterior, primary
$82.62
D4210
gingivectomy - gingivoplast/quad
$258.30
D2331
resin - 2 surfaces, anterior
$104.49
D4211
gingivectomy(plasty) per tooth
$100.62
D2332
resin - 3 surfaces, anterior
$131.04
D4240
gingival flap w/root plan/quad
$294.39
D2335
resin - 4+ surfaces, anterior
$157.59
D4241
gingival flap w/root plan 1-3/quad
$176.58
D2390
composite crown – anterior
$189.90
D4249
crown lengthening - hard tissue
$379.80
D2391
composite - 1 surface, post- permanent
$69.30
D4260
osseous surgery - per quadrant
$470.97
D2392
composite - 2 surfaces, post$83.52
D4261
osseous surgery –1-3 teeth/quad
$307.62
permanent
D4263
bone replacement graft; first site in
$261.09
D2393
composite – 3 surfaces, post-permanent
$100.62
quadrant
D2394
composite – 4+ surfaces, post-primary
$120.60
D4264
bone replacement graft; each additional
$246.87
D2750
crown - porce fused to high noble
$540.27
site in quadrant
D2751
crown - porcelain fused to metal
$540.27
D4265
biologic material to aid in soft and
$280.08
D2752
crown - porce fused to noble metal
$540.27
osseous tissue regeneration
D2790
crown - full cast high noble
$540.27
D4266
guided tissue regeneration; resorbable
$268.74
D2791
crown - full cast base metal
$540.27
barrier; per site
121001 AZ Maricopa & UFC MA MC
A-4-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4267
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D6930
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
Description
guided tissue regeneration; nonresorbable barrier; per site
pedicle soft tissue graft proc
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site
surgery)
distal or proximal wedge procedure
(when not performed in conjunction
with surgical procedures in the same
anatomical area)
soft tissue allograft
combined connective tissue and double
pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3
teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
recement fixed partial denture
coronal remnants-primary tooth
extraction – erupted tooth/exposed root
surgical removal erupted tooth
removal impacted tooth - soft
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
surg remove residual roots
oroantral fistula closure
Fee
$289.62
$288.63
$343.71
$488.97
Code
D7261
D7270
D7280
D7281
D7282
$302.85
D7283
$380.79
$493.74
D7285
D7286
D7310
D7311
$167.13
$128.16
$137.70
$81.63
$71.19
$68.40
$28.53
$700.74
$700.74
$786.15
$786.15
$655.20
$655.20
$769.14
$769.14
$341.82
$37.98
$37.98
$37.98
$37.98
$100.62
$76.95
$70.29
$80.73
$82.62
$76.95
$91.17
$121.50
$292.41
$292.41
$292.41
$292.41
$161.46
$161.46
$148.14
$148.14
$225.99
$225.99
$191.79
$191.79
$322.83
$322.83
$80.73
$80.73
$43.65
$54.00
$79.20
$121.50
$149.04
$189.90
$222.21
$275.40
$121.50
$284.85
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
Description
primary closure of a sinus perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or
unerupted tooth
mobilization of erupted or
malpositioned tooth to aid eruption
placement of device to facilitate
eruption of impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or tooth
spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion – 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion, complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion,
complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25 cm
removal nonodontogenic cyst->1.25
cm
destruction of lesion(s) by physical or
chemical method
removal of lateral exotosis-(maxilla of
mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscessintraoral soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscessextraoral soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction – immobilized
max- closed reduction – immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch –open reduction
malar/zygo arch –closed reduction
alveolus-closed reduction
alveolus- open reduction
facial bones-complicated reduction
max-open reduction-compound
max-closed reduction – compound
mand – open reduction-compound
mand- closed reduction-compound
malar/zygo-open reduction- compound
malar/zygo-closed reductioncompound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
121001 AZ Maricopa & UFC MA MC
A-4-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$284.85
$275.40
$205.11
$123.48
$123.48
$50.31
$145.26
$145.26
$144.36
$91.17
$189.90
$126.27
$100.62
$223.11
$261.09
$199.44
$294.39
$308.61
$194.67
$289.62
$144.36
$185.13
$105.39
$139.50
$67.50
$225.00
$315.00
$495.00
$256.50
$3,105.00
$67.50
$225.00
$121.50
$247.50
$83.70
$103.50
$171.00
$328.50
$1,575.00
$1,125.00
$1,918.80
$990.00
$1,125.00
$765.00
$308.70
$1,552.50
$2,565.00
$1,755.00
$1,075.50
$1,845.00
$1,161.00
$1,687.50
$1,165.50
$1,125.00
$652.50
$3,231.00
Code
D7810
D7820
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
Description
open reduction-dislocation
closed reduction-dislocation
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or without
biopsy
arthroscopy-surgical: lavage and lysis o
arthroscopy-surgical: disc repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with bone
graft, includes obtaining the graft
osteotomy-segmented or subapical-per
sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal, or
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous tuberosity
sialolithotomy
excision of salivary gland-by report
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
limited orthodontic treatment or the
adolescent dentition
limited orthodontic treatment or the
adult dentition
interceptive orthodontic treatment of
the primary dentition
interceptive orthodontic treatment of
the transitional dentition
comprehensive orthodontic treatment
of the transitional dentition
comprehensive orthodontic treatment
of the adolescent dentition
comprehensive orthodontic treatment
of the adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
Fee
$1,611.00
$139.50
$211.50
$2,047.50
$1,867.50
$2,331.00
$1,222.20
$2,445.30
$481.50
$2,445.30
$148.50
$270.00
$418.50
$1,093.50
$1,093.50
$1,477.80
$1,477.80
$2,445.30
$299.70
$224.10
$63.00
$106.20
$247.50
$1,125.00
$3,105.00
$3,105.00
$2,605.50
$2,812.50
$3,141.00
$2,875.50
$3,599.10
$3,735.00
$805.50
$814.50
$131.40
$131.40
$136.80
$66.60
$112.50
$175.50
$679.50
$495.00
$184.50
$328.50
$1,147.50
$265.86
Code
D8670
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
D9920
D9930
D9940
D9951
Description
periodic orthodontic treatment visit
orthodontic retention (removal of
appliances, construction, and
placement of retainers)
orthodontic treatment (alternative
billing to contracted fee)
replacement of lost or broken retainer
rebonding or recementing and/or repair
of fixed retainer
palliative (emergency) treat
fixed partial denture sectioning
local anesthesia non-surgical
gen anesthesia - first 30 minutes
gen anesthesia – each add’l 15 min
analgesia
intravenous conscious
sedation/analgesia; first 30 minutes
intravenous conscious
sedation/analgesia; each additional 15
minutes
non-intavenous conscious sedation
consultation
house call
hospital call
office visit for observation
office visit - after hours
therapeutic drug injection
theraputic parenteral drugs
behavior management-by report
treat complication (post-surg)
occlusal guard – by report
occlusal adjustment –limited
$265.86
$265.86
$265.86
$1,234.35
$1,234.35
$2,468.70
$2,776.32
$2,873.16
$289.62
$318.06
$42.75.
121001 AZ Maricopa & UFC MA MC
A-4-3
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$125.37
$189.90
$61.74
$123.48
$43.65
$54.09
$49.41
$9.54
$131.40
$61.20
$23.76
$126.27
$36.09
$56.97
$36.99
$42.75
$75.96
$26.55
$59.85
$18.00
$28.53
$33.21
$26.55
$170.91
$46.53
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
A-4-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT A-5
DENTAQUEST OF ARIZONA, LLC
SCHEDULE OF ALLOWABLE FEES-SPECIALISTS-PIMA & YAVAPAI COUNTY
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES**
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$28.03
D2752
crown - porce fused to noble metal
$570.28
D0140
limited oral evaluation
$37.05
D2790
crown - full cast high noble
$570.28
D0145
oral evaluation for patient under three
$35.06
D2791
crown - full cast base metal
$570.28
years of age and counseling
D2792
crown - full cast noble metal
$570.28
D0150
comprehensive oral evaluation
$41.13
D2794
crown - titanium
$380.00
D0160
detailed and extensive oral
$41.13
D2910
recement inlay
$46.08
evaluation-problem focused
D2915
recement cast or prefabricated post
$46.08
D0180
comprehensive periodontal
$43.13
and core
evaluation - new or established
D2920
recement crown
$46.08
patient
D2930
prefab steel crown - prime tooth
$135.28
D0210
intraoral-comp (inc bitewings)
$73.15
D2931
prefab steel crown - perm tooth
$157.32
D0220
intraoral-periapical - 1st film
$15.01
D2932
prefabricated resin crown
$133.28
D0230
intraoral-periapical - each film
$12.07
D2933
prefab steel crown w/resin win
$158.37
D0240
intraoral - occlusal film
$15.01
D2934
prefab esthetic coated stainless steel
$158.37
D0250
extraoral - first film
$17.01
crown-pr
D0260
extraoral - each additional film
$13.02
D2940
sedative filling
$51.11
D0270
bitewing - single film
$12.07
D2950
core buildup, including pins
$140.32
D0272
bitewings - two films
$24.03
D2951
pin retention - per tooth
$40.09
D0273
bitewings0three films
$30.12
D2952
cast post and core plus crown
$212.52
D0274
bitewings - four films
$35.06
D2970
temporary crown (fracture)
$105.26
D0277
vertical bitewings-7 to 8 films
$35.06
D3110
pulp cap - direct
$19.00
D0290
skull and facial bone film
$37.05
D3120
pulp cap - indirect
$19.00
D0310
$52.25
D3220
therapeutic pulpotomy
$81.23
Sialography
D0320
temporomandibular joint arthrogram,
$115.23
D3221
gross pupal debridement, primary and
$81.23
incl
permanent teeth
D0321
other TMJ films, by report
$55.10
D3230
pulpal therapy - anterior
$104.50
D0330
panoramic film
$62.13
D3240
pulpal therapy - posterior
$104.50
D0340
cephalometric film
$53.11
D3310
anterior (exc final rest)
$370.88
D0350
oral/facial images (includes intra and
$21.09
D3320
bicuspid (exc final restore)
$448.02
extraoral images)
D3330
molar (excluding final restore)
$562.31
D0470
diagnostic casts
$52.16
D3331
treatment of root canal obstruction;
$104.22
D0502
other oral pathology procedures, by
$25.08
non-surgical access
repo
D3332
incomplete endodontic therapy;
$213.47
D1110
prophylaxis - adult
$50.16
inoperable or fractured tooth
D1120
prophylaxis - child
$43.13
D3333
internal root repair or perforation
$118.28
D1203
fluoride w/o prophy - child
$19.95
defects
D1204
fluoride w/o prophy - adult
$19.95
D3346
retreat prior root canal - anterior
$476.04
D1206
topical fluoride varnish, theraputic
$19.95
D3347
retreat prior root canal - bicuspid
$501.13
appl
D3348
retreatment root canal - molar
$596.32
D1351
sealant - per tooth
$27.08
D3351
apexification/recalc - 1st visit
$89.21
D1510
space maintainer - fixed-uni
$149.34
D3352
apexification/recalcification
$75.14
D1515
space maintainer - fixed-bilateral
$213.47
D3353
apexification/recalcification
$240.54
D1520
space maintainer - removable-uni
$149.34
D3410
apicoectomy/periradicular - ant
$340.77
D1525
space maintainer - removable-bi
$213.47
D3421
apicoectomy surgery - bicuspid
$340.77
D1550
recementation space maintainer
$34.11
D3425
apicoectomy surgery - molar 1st
$394.92
D1555
removal of fixed space maintainer
$34.11
D3426
apicoectomy surgery (each root)
$170.43
D2140
amalgam - 1 surface, permanent
$73.15
D3430
retrograde filling - per root
$119.23
D2150
amalgam - 2 surfaces, permanent
$88.16
D3450
root amputation - per root
$196.46
D2160
amalgam - 3 surfaces, permanent
$106.21
D3470
intentional replantation
$427.98
D2161
amalgam - 4+ surfaces, permanent
$127.30
D3920
hemisection
$196.46
D2330
resin - 1 surface, anterior, primary
$87.21
D4210
gingivectomy - gingivoplast/quad
$272.65
D2331
resin - 2 surfaces, anterior
$110.29
D4211
gingivectomy(plasty) per tooth
$106.21
D2332
resin - 3 surfaces, anterior
$138.32
D4240
gingival flap w/root plan/quad
$310.74
D2335
resin - 4+ surfaces, anterior
$166.34
D4241
gingival flap w/root plan 1-3/quad
$186.39
D2390
composite crown - anterior
$200.45
D4249
crown lengthening - hard tissue
$400.90
D2391
composite - 1 surface, post$73.15
D4260
osseous surgery - per quadrant
$497.13
permanent
D4261
osseous surgery -1-3 teeth/quad
$324.71
D2392
composite - 2 surfaces, post$88.16
D4263
bone replacement graft; first site in
$275.59
permanent
quadrant
D2393
composite - 3 surfaces, post$106.21
permanent
D2394
composite - 4+ surfaces, post-primary
$127.30
D2750
crown - porce fused to high noble
$570.28
D2751
crown - porcelain fused to metal
$570.28
121001 AZ Maricopa & UFC MA MC
A-5-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4264
D4265
D4266
D4267
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D6930
D7111
D7140
Description
bone replacement graft; each
additional site in quadrant
biologic material to aid in soft and
osseous tissue regeneration
guided tissue regeneration; resorbable
barrier; per site
guided tissue regeneration; nonresorbable barrier; per site
pedicle soft tissue graft proc
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site
surgery)
distal or proximal wedge procedure
(when not performed in conjunction
with surgical procedures in the same
anatomical area)
soft tissue allograft
combined connective tissue and
double pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3
teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
recement fixed partial denture
coronal remnants-primary tooth
extraction - erupted tooth/exposed
root
Fee
$260.58
$295.64
$283.67
$305.71
$304.67
$362.81
$516.13
Code
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7280
D7281
D7282
$319.68
D7283
$401.94
$521.17
$176.42
$135.28
$145.35
$86.17
$75.14
$72.20
$30.12
$739.67
$739.67
$829.83
$829.83
$691.60
$691.60
$811.87
$811.84
$360.81
$40.09
$40.09
$40.09
$40.09
$106.21
$81.23
$74.19
$85.22
$87.21
$81.23
$96.23
$128.25
$308.66
$308.66
$308.66
$308.66
$170.43
$170.43
$156.37
$156.37
$238.54
$238.54
$202.44
$204.44
$340.77
$340.77
$85.22
$85.22
$46.08
$57.00
$83.60
D7285
D7286
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
Description
surgical removal erupted tooth
removal impacted tooth - soft
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
surg remove residual roots
oroantral fistula closure
primary closure of a sinus perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or
unerupted tooth
mobilization of erupted or
malpositioned tooth to aid eruption
placement of device to facilitate
eruption of impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or
tooth spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion - 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion,
complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion,
complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25
cm
removal nonodontogenic cyst->1.25
cm
destruction of lesion(s) by physical or
chemical method
removal of lateral exotosis-(maxilla
of mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous
tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscessintraoral soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscessextraoral soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction - immobilized
max- closed reduction - immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch -open reduction
malar/zygo arch -closed reduction
alveolus-closed reduction
alveolus- open reduction
121001 AZ Maricopa & UFC MA MC
A-5-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$128.25
$157.32
$200.45
$234.56
$290.70
$128.25
$300.68
$300.68
$290.70
$216.51
$130.34
$130.34
$53.11
$153.36
$153.33
$152.38
$96.23
$200.45
$133.28
$106.21
$235.51
$275.59
$210.52
$310.74
$325.76
$205.48
$305.71
$152.38
$195.42
$111.24
$147.25
$71.25
$237.50
$332.50
$522.50
$270.75
$3,277.50
$71.25
$237.50
$128.25
$261.25
$88.35
$109.25
$180.50
$346.75
$1,662.50
$1,187.50
$2,025.40
$1,045.00
$1,187.50
$807.50
$325.85
$1,638.75
Code
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D8010
D8020
Description
facial bones-complicated reduction
max-open reduction-compound
max-closed reduction - compound
mand - open reduction-compound
mand- closed reduction-compound
malar/zygo-open reductioncompound
malar/zygo-closed reductioncompound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
open reduction-dislocation
closed reduction-dislocation
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or
without biopsy
arthroscopy-surgical: lavage and lysis
o
arthroscopy-surgical: disc
repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with
bone graft, includes obtaining the
graft
osteotomy-segmented or subapicalper sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal,
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous
tuberosity
sialolithotomy
excision of salivary gland-by report
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
Fee
$2,707.50
$1,852.50
$1,135.25
$1,947.50
$1,225.50
$1,781.25
Code
D8030
D8040
D8050
D8060
$1,230.25
D8070
$1,187.50
$688.75
$3,410.50
$1,700.50
$147.25
$223.25
$2,161.25
$1,971.25
$2,460.50
$1,290.10
$2,581.15
$508.25
$2,581.15
$156.75
$285.00
$441.75
$1,154.25
$1,154.25
$1,559.90
$1,559.90
$2,581.15
$316.35
$236.55
$66.50
$112.13
$261.25
$1,187.50
$3,277.50
$3,277.50
$2,750.25
$2,968.75
$3,315.50
$3,035.25
$3,799.05
$3,942.50
$850.25
$859.75
$138.70
$138.70
$144.40
$70.30
$118.75
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
D9920
D9930
D9940
D9951
Description
limited orthodontic treatment or the
adolescent dentition
limited orthodontic treatment or the
adult dentition
interceptive orthodontic treatment of
the primary dentition
interceptive orthodontic treatment of
the transitional dentition
comprehensive orthodontic treatment
of the transitional dentition
comprehensive orthodontic treatment
of the adolescent dentition
comprehensive orthodontic treatment
of the adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
periodic orthodontic treatment visit
orthodontic retention (removal of
appliances, construction, and
placement of retainers)
orthodontic treatment (alternative
billing to contracted fee)
replacement of lost or broken retainer
rebonding or recementing and/or
repair of fixed retainer
palliative (emergency) treat
fixed partial denture sectioning
local anesthesia non-surgical
gen anesthesia - first 30 minutes
gen anesthesia - each add'l 15 min
analgesia
intravenous conscious
sedation/analgesia; first 30 minutes
intravenous conscious
sedation/analgesia; each additional 15
minutes
non-intavenous conscious sedation
consultation
house call
hospital call
office visit for observation
office visit - after hours
therapeutic drug injection
theraputic parenteral drugs
behavior management-by report
treat complication (post-surg)
occlusal guard - by report
occlusal adjustment -limited
$185.25
$717.25
$522.50
$194.75
$346.75
$1,211.25
$280.63
$280.63
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A-5-3
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$280.63
$280.63
$1,302.93
$1,302.93
$2,605.85
$2,930.56
$3,032.78
$305.71
$335.73
$45.13
$132.33
$200.45
$65.17
$130.34
$46.08
$57.09
$52.16
$10.07
$138.70
$64.60
$25.08
$133.28
$38.09
$60.13
$39.04
$45.13
$80.18
$28.03
$63.18
$19.00
$30.12
$35.06
$28.03
$180.41
$49.12
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121001 AZ Maricopa & UFC MA MC
A-5-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT B
AHCCCS STANDARD SUBCONTRACT
TERMS AND CONDITIONS ("Subcontract")
(The provisions of this Subcontract are incorporated in the Agreement by reference).
1.
EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the U.S. Department of Health and
Human Services may evaluate, through inspection or other means, the quality, appropriateness or timeliness of services
performed under this subcontract.
2.
RECORDS AND REPORTS
The Subcontractor shall maintain all forms, records, reports, and working papers used in the preparation of reports, files,
correspondence, financial statements, records relating to quality of care, medical records, prescription files, statistical
information and other records specified by AHCCCSA, for purposes of audit and program management. The
Subcontractor shall comply with all specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect each service provided and all net costs, direct
and indirect, of labor, materials, equipment, supplies and services, and other costs and expenses of whatever nature for
which payment is made to the Subcontractor. Such material shall be subject to inspection and copying by the state,
AHCCCSA and the U.S. Department of Health and Human Services during normal business hours at the place of business
of the person or organization maintaining the records.
The Subcontractor agrees to make available at the office of the Subcontractor at all reasonable times any of its records for
inspection, audit or reproduction, by any authorized representative of the state or federal governments.
The Subcontractor shall preserve and make available all records for a period of five years from the date of final payment
under this subcontract except as provided in paragraphs a. and b. below:
a.
If this subcontract is completely or partially terminated, the records relating to the work terminated shall be
preserved and made available for a period of five years from the date of any such termination.
b.
Records which relate to disputes, litigation or the settlement of claims arising out of the performance of this
subcontract, or costs and expenses of this subcontract to which exception has been taken by the state, shall be
retained by the Subcontractor until such disputes, litigation, claims or exceptions have been disposed of.
The Subcontractor shall provide all reports requested by AHCCCSA, and all information from records relating to the
performance of the Subcontractor which AHCCCSA may reasonably require. The Subcontractor reporting
requirements may include, but are not limited to, timely and detailed utilization statistics, information and reports.
Social Security Act (42 USC 1320a-7b).
3.
LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Subcontractor shall not bill nor attempt to collect payment directly or through a collection agency from a person
claiming to be AHCCCS eligible without first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered services. This provision shall not
apply to patient contributions to the cost of services delivered by nursing homes.
4.
ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Subcontractor under this subcontract may be assigned without the prior approval of AHCCCSA. No
assignment or delegation of the duties of this subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5.
APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The Contractor shall notify AHCCCSA in the event of any
proposed amendment or termination during the term hereof. Any such amendment or termination is subject to the
121001 AZ Maricopa & UFC MA MC
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
prior approval by AHCCCSA. Approval of the subcontract may be rescinded by the Director of AHCCCSA for violation
of federal or state laws or rules.
6.
WARRANTY OF SERVICES
The Subcontractor, by execution of this subcontract, warrants that it has the ability, authority, skill, expertise and capacity
to perform the services specified in this contract.
7.
SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms and conditions of the contract existing
between the Contractor and AHCCCSA for the provision of covered services.
8.
AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the Contractor may undertake or award other contracts for additional or related work to the work
performed by the Subcontractor and the Subcontractor shall fully cooperate with such other contractors, subcontractors or
state employees. The Subcontractor shall not commit or permit any act which will interfere with the performance of work
by any other contractor, subcontractor or state employee.
9.
INDEMNIFICATION BY SUBCONTRACTOR
The Subcontractor agrees to hold harmless the state, all state officers and employees, AHCCCSA and other appropriate
state agencies, and all officers and employees of AHCCCSA and all AHCCCS eligible persons in the event of
nonpayment to the Subcontractor. The Subcontractor shall further indemnify and hold harmless the state, AHCCCSA,
other appropriate state agencies, AHCCCS contractors, and their agents, officers and employees against all injuries,
deaths, losses, damages, claims, suits, liabilities, judgments, costs and expenses which may, in any manner, accrue against
the state, AHCCCSA, or its agents, officers or employees, or AHCCCS contractors, through the intentional conduct,
negligence or omission of the Subcontractor, its agent, officers or employees.
10.
MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Subcontractor shall be registered with AHCCCSA and shall obtain and maintain all licenses, permits and authority
necessary to do business and render service under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's compensation.
11.
COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Subcontractor shall comply with all federal, state and local laws, rules, regulations, standards and executive orders
governing performance of duties under this subcontract, without limitation to those designated within this subcontract.
12.
SEVERABILITY
If any provision of these standard subcontract terms and conditions is held invalid or unenforceable, the remaining
provisions shall continue valid and enforceable to the full extent permitted by law.
13.
VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA upon the Subcontractor becoming
insolvent or filing proceedings in bankruptcy or reorganization under the United States Code, or upon assignment or
delegation of the subcontract without AHCCCSA's prior written approval.
14.
CONFIDENTIALITY REQUIREMENT
-107, 36-2903, 411959 and 46-135, and AHCCCS and/or ALTCS Rules.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
15.
GRIEVANCE PROCEDURES
Any grievances filed by the Subcontractor shall be adjudicated in accordance with AHCCCS Rules.
16.
TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Subcontractor, terminate this subcontract if it is found, after notice and hearing
by the state, that gratuities in the form of entertainment, gifts, or otherwise were offered or given by the Subcontractor, or
any agent or representative of the Subcontractor, to any officer or employee of the state with a view towards securing a
contract or securing favorable treatment with respect to the awarding, amending or the making of any determinations with
respect to the performance of the Subcontractor; provided, that the existence of the facts upon which the state makes such
findings shall be in issue and may be reviewed in any competent court. If the subcontract is terminated under this section,
unless the Contractor is a governmental agency, instrumentality or subdivision thereof, AHCCCSA shall be entitled to a
penalty, in addition to any other damages to which it may be entitled by law, and to exemplary damages in the amount of
three times the cost incurred by the Subcontractor in providing any such gratuities to any such officer or employee.
17.
PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The Contractor and Subcontractor shall develop, maintain and use a system for Prior Authorization and Utilization
Review which is consistent with AHCCCS Rules and the Contractor's policies.
18.
NON-DISCRIMINATION REQUIREMENTS
If applicable, the Subcontractor shall comply with:
19.
a.
The Equal Pay Act of 1963, as amended, which prohibits sex discrimination in the payment of wages to men and
women performing substantially equal work under similar working conditions in the same establishment.
b.
Title VI of the Civil Rights Act of 1964, as amended, which prohibits the denial of benefits of, or participation in,
contract services on the basis of race, color, or national origin.
c.
Title VII of the Civil Rights Act of 1964, as amended, which prohibits private employers, state and local
governments, and educational institutions from discriminating against their employees and job applicants on the
basis of race, religion, color, sex, or national origin.
d.
Title I of the Americans with Disabilities Act of 1990, as amended, which prohibits private employers and state and
local governments from discriminating against job applicants and employees on the basis of disability.
e.
The Civil Rights Act of 1991, which reverses in whole or in part, several recent Supreme Court decisions
interpreting Title VII.
f.
The Age Discrimination in Employment Act (ARS Title 41-1461, et seq.); which prohibits discrimination based on
age.
g.
State Executive Order 75-5 and Federal Order 11246 which mandates that all persons, regardless of race, color,
religion, sex, age, national origin or political affiliation, shall have equal access to employment opportunities.
h.
Section 503 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination in the employment or
advancement of the employment of qualified persons because of physical or mental handicap.
i.
Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination on the basis of handicap
in delivering contract services.
COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide relating to the audit of the
Subcontractor's records and the inspection of the Subcontractor's facilities. If the Subcontractor is an inpatient facility, the
Subcontractor shall file uniform reports and Title XVIII and Title XIX cost reports with AHCCCSA.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
20.
CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Subcontractor certifies that all representations set forth herein are true to the best of its
knowledge.
21.
CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Subcontractor certifies that it has not engaged in any violation of the Medicare AntiKickback statute (42 USC 1320a-7b) or the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Subcontractor provides laboratory testing, it certifies that it has
complied with 42 CFR 411.361 and has sent to AHCCCSA simultaneous copies of the information required by that rule
to be sent to the Health Care Financing Administration.
22.
CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this subcontract and the AHCCCS Minimum
Subcontract Provisions, the latter shall take precedence.
23.
ENCOUNTER DATA REQUIREMENT
If Subcontractor does not bill the Contractor (e.g., Subcontractor is capitated), the Subcontractor shall submit encounter
data to the Contractor in a form acceptable to AHCCCSA.
24.
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires laboratories and other facilities that test
human specimens to obtain either a CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the requirements of 42 CFR 493, Subpart
A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to provide verification of CLIA
Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration. These requirements apply to all clinical
laboratories.
Pass-through billing or other similar activities with the intent of avoiding the above requirements are prohibited.
Contractor may not reimburse providers who do not comply with the above requirements.
25.
INSURANCE
The Subcontractor shall maintain for the duration of this subcontract a policy or policies of professional liability
insurance, comprehensive general liability insurance and automobile liability insurance. The Subcontractor agrees that
any insurance protection required by this subcontract, or otherwise obtained by the Subcontractor, shall not limit the
responsibility of Subcontractor to indemnify, keep and save harmless and defend the state and AHCCCSA, their agents,
officers and employees as provided herein. Furthermore, the Subcontractor shall be fully responsible for all tax
obligations, Worker's Compensation Insurance, and all other applicable insurance coverage, for itself and its employees,
and AHCCCSA shall have no responsibility or liability for any such taxes or insurance coverage.
26.
FRAUD AND ABUSE
If the Subcontractor discovers, or is made aware, that an incident of potential fraud or abuse has occurred, the
Subcontractor shall report the incident to the Contractor, who shall proceed in accordance with the AHCCCS Health Plans
and Program Contractors Policy for Prevention, Detection and Reporting of Fraud and Abuse. Incidents involving
potential member eligibility fraud should be reported to AHCCCSA, Office of Managed Care, Member Fraud Unit. All
other incidents of potential fraud should be reported to AHCCCSA, Office of the Director, Office of Program Integrity.
(See AHCCCS Rule R9-22-511.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT C
MARICOPA CARE ADVANTAGE PLAN
DENTAL REIMBURSEMENT SCHEDULE
Provider Reimbursement
1.0
Provider shall be paid the lesser of billed charges or 100% of the fee schedule attached hereto as Maricopa
Care Advantage Fee Schedule Attachment for the provision of Medically Necessary Covered Services as
determined by DentaQuest to eligible Maricopa Care Advantage Members.
2.0
Provider agrees to practice cost effective dentistry. Provider acknowledges that improper billing or the
rendering of dental care that is determined to be unnecessary or inappropriate by the DentaQuest Dental
Director, shall not be compensated and will constitute sufficient basis for termination of this agreement or
other measures as described in paragraph 3.0.
3.0
Provider acknowledges that “fee-for-service” dental reimbursement can only be maintained with the
cooperation and commitment of all dental panel members to practice cost effective, quality dentistry.
DentaQuest shall compile an internal “practice profile” for each member of the DentaQuest dental panel on
a periodic basis. This profile will compute averages for total cost per patient. Providers, whose practice
patterns deviate in a statistically significant way from the norms of the DentaQuest dental panel, may be
subject to notice of probationary status and/or possible termination, subject to the appropriate notice and
appeal procedures as stated herein.
4.0
DentaQuest shall pay Provider within thirty (30) calendar days of receipt of clean claims for dental services
rendered to Members. Provider agrees to accept electronic payment and electronic remittances if/when
available.
Provider reimbursement requires receipt of a clean claim. A claim shall be considered clean only if the
claim requires no further information, documentation, adjustment or alteration by Provider to be
adjudicated by DentaQuest. Any dispute regarding payment shall be deemed waived unless Provider
submits written notification of the reasons for the dispute within sixty (60) days of receipt of the payment,
statement of denial or adjustment.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT C-1
MARICOPA ADVANTAGE PLAN
SCHEDULE OF MAXIMUM ALLOWABLE FEES
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES**
Code
Description
Fee
D0120 periodic oral evaluation
$27.02
D0150 comprehensive oral evaluation
$29.52
D0270 bitewing - single film
$11.92
D0272 bitewings - two films
$20.29
D0274 bitewings - four films
$28.62
D1110 prophylaxis - adult
$48.81
D1120 prophylaxis - child
$42.49
D1203 fluoride w/o prophy - child
$19.84
D1204 fluoride w/o prophy - adult
$16.02
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT D
DENTAQUEST OF ARIZONA, LLC
UNIVERSITY FAMILY CARE
DENTAL PANEL REIMBURSEMENT
Provider Reimbursement
1.0
Provider shall be paid the lesser of billed charges, or 100% of the fee schedule attached hereto as
Attachment D-1 for the provision of Medically Necessary Covered Services as determined by DentaQuest
to eligible University Family Care Members.
2.0
Provider agrees to practice cost effective dentistry. Provider acknowledges that improper billing or the
rendering of dental care that is determined to be unnecessary or inappropriate by the DentaQuest Dental
Director, shall not be compensated and will constitute sufficient basis for termination of this agreement or
other measures as described in paragraph 3.0.
3.0
Provider acknowledges that “fee-for-service” dental reimbursement can only be maintained with the
cooperation and commitment of all dental panel members to practice cost effective, quality dentistry.
DentaQuest shall compile an internal “practice profile” for each member of the DentaQuest dental panel on
a periodic basis. This profile will compute averages for total cost per patient. Providers, whose practice
patterns deviate in a statistically significant way from the norms of the DentaQuest dental panel, may be
subject to notice of probationary status and/or possible termination, subject to the appropriate notice and
appeal procedures as stated herein.
4.0
DentaQuest shall pay Provider within thirty (30) calendar days of receipt of clean claims for dental services
rendered to Members. Provider agrees to accept electronic payment and electronic remittances if/when
available.
Provider reimbursement requires receipt of a clean claim. A claim shall be considered clean only if the
claim requires no further information, documentation, adjustment or alteration by Provider to be
adjudicated by DentaQuest. Any dispute regarding payment shall be deemed waived unless Provider
submits written notification of the reasons for the dispute within sixty (60) days of receipt of the payment,
statement of denial or adjustment.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
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121001 AZ Maricopa & UFC MA MC
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
ATTACHMENT D-1
DENTAQUEST OF ARIZONA, LLC
UNIVERSITY FAMILY CARE
SCHEDULE OF ALLOWABLE FEES
** PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES**
Code
Description
Fee
Code
Description
Fee
D0120
periodic oral evaluation
$23.77
D2792
crown - full cast noble metal
$483.81
D0140
limited oral evaluation
$31.44
D2794
crown - titanium
$322.37
D0145
oral evaluation for patient under three years
D2910
recement inlay
$39.08
of age and counseling
$29.74
D2915
recement cast or prefabricated post & core
$39.08
D0150
comprehensive oral evaluation
$34.90
D2920
recement crown
$39.08
D0160
detailed and extensive oral evaluationD2930
prefab steel crown - prime tooth
$114.77
problem focused
$34.90
D2931
prefab steel crown - perm tooth
$133.47
D0180
comprehensive periodontal evaluation D2932
prefabricated resin crown
$113.08
new or established patient
$36.59
D2933
prefab steel crown w/resin win
$134.36
D0210
intraoral-comp (inc bitewings)
$62.05
D2934
prefab esthetic coated stainless steel crownD0220
intraoral-periapical - 1st film
$12.73
pr
$134.36
D0230
intraoral-periapical - each film
$10.23
D2940
sedative filling
$43.36
D0240
intraoral - occlusal film
$12.73
D2950
core buildup, including pins
$119.04
D0250
extraoral - first film
$14.43
D2951
pin retention - per tooth
$34.02
D0260
extraoral - each additional film
$11.05
D2952
cast post and core plus crown
$180.29
D0270
bitewing - single film
$10.23
D2954
prefab post & core
$112.83
D0272
bitewings - two films
$20.39
D2970
temporary crown (fracture)
$89.29
D0273
bitewings0three films
$25.55
D3110
pulp cap - direct
$16.12
D0274
bitewings - four films
$29.74
D3120
pulp cap - indirect
$16.12
D0277
vertical bitewings-7 to 8 films
$29.74
D3220
therapeutic pulpotomy
$68.90
D0290
skull and facial bone film
$31.44
D3221
gross pupal debridement, primary and
D0310
sialography
$49.72
permanent teeth
$68.90
D0320
temporomandibular joint arthrogram, incl
$97.76
D3230
pulpal therapy - anterior
$88.65
D0321
other TMJ films, by report
$46.74
D3240
pulpal therapy - posterior
$88.65
D0330
panoramic film
$52.72
D3310
anterior (exc final rest)
$314.64
D0340
cephalometric film
$45.05
D3320
bicuspid (exc final restore)
$380.08
D0350
oral/facial images (includes intra and
D3330
molar (excluding final restore)
$477.03
extraoral images)
$17.90
D3331
treatment of root canal obstruction; nonD0470
diagnostic casts
$44.25
surgical access
$88.41
D0502
other oral pathology procedures, by repo
$21.28
D3332
incomplete endodontic therapy; inoperable
D1110
prophylaxis - adult
$42.55
or fractured tooth
$181.10
D1120
prophylaxis - child
$36.59
D3333
internal root repair or perforation defects
$100.34
D1203
fluoride w/o prophy - child
$16.92
D3346
retreat prior root canal - anterior
$403.85
D1204
fluoride w/o prophy - adult
$16.92
D3347
retreat prior root canal - bicuspid
$425.13
D1206
topical fluoride varnish, theraputic appl
$16.92
D3348
retreatment root canal - molar
$505.88
D1310
nutritional counseling for control of dental
D3351
apexification/recalc - 1st visit
$75.69
disease
$21.68
D3352
apexification/recalcification
$63.75
D1351
sealant - per tooth
$22.97
D3353
apexification/recalcification
$204.06
D1510
space maintainer - fixed-uni
$126.69
D3410
apicoectomy/periradicular - ant
$289.09
D1515
space maintainer - fixed-bilateral
$181.10
D3421
apicoectomy surgery - bicuspid
$289.09
D1520
space maintainer - removable-uni
$126.69
D3425
apicoectomy surgery - molar 1st
$335.03
D1525
space maintainer - removable-bi
$181.10
D3426
apicoectomy surgery (each root)
$144.59
D1550
recementation space maintainer
$28.94
D3430
retrograde filling - per root
$101.15
D1555
removal of fixed space maintainer
$28.94
D3450
root amputation - per root
$166.67
D2140
amalgam - 1 surface, permanent
$62.05
D3470
intentional replantation
$363.08
D2150
amalgam - 2 surfaces, permanent
$74.79
D3920
hemisection
$166.67
D2160
amalgam - 3 surfaces, permanent
$90.11
D4210
gingivectomy - gingivoplast/quad
$231.31
D2161
amalgam - 4+ surfaces, permanent
$108.00
D4211
gingivectomy(plasty) per tooth
$90.88
D2330
resin - 1 surface, anterior, primary
$73.99
D4240
gingival flap w/root plan/quad
$263.63
D2331
resin - 2 surfaces, anterior
$93.57
D4241
gingival flap w/root plan 1-3/quad
$158.13
D2332
resin - 3 surfaces, anterior
$117.34
D4249
crown lengthening - hard tissue
$340.11
D2335
resin - 4+ surfaces, anterior
$141.11
D4260
osseous surgery - per quadrant
$421.74
D2390
composite crown – anterior
$170.05
D4261
osseous surgery –1-3 teeth/quad
$275.47
D2391
composite - 1 surface, post- permanent
$62.05
D4263
bone replacement graft; first site in
D2392
composite - 2 surfaces, post- permanent
$74.79
quadrant
$233.80
D2393
composite – 3 surfaces, post-permanent
$90.11
D4264
bone replacement graft; each additional site
D2394
composite – 4+ surfaces, post-primary
$108.00
in quadrant
$221.07
D2712
crown-3/4 resin based composite-indirect
$178.08
D4265
biologic material to aid in soft and osseous
D2750
crown - porce fused to high noble
$483.81
tissue regeneration
$250.81
D2751
crown - porcelain fused to metal
$483.81
D4266
guided tissue regeneration; resorbable
D2752
crown - porce fused to noble metal
$483.81
barrier; per site
$240.65
D2790
crown - full cast high noble
$483.81
D4267
guided tissue regeneration; non-resorbable
D2791
crown - full cast base metal
$483.81
barrier; per site
$259.35
121001 AZ Maricopa & UFC MA MC
D-1-1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Code
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5811
D5820
D5821
D5850
D5851
D5862
D6930
D7110
D7111
D7120
D7130
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
Description
pedicle soft tissue graft proc
free soft tissue graft proc
subepithelial connective tissue graft
procedure (including donor site surgery)
distal or proximal wedge procedure (when
not performed in conjunction with surgical
procedures in the same anatomical area)
soft tissue allograft
combined connective tissue and double
pedicle graft
provision splint - intracoronal
provision splint - extracoronal
perio scaling & root plan/quad
perio scaling & root plan 1-3 teeth/quad
full mouth debridement
periodontal maintenance proc
unscheduled dressing change
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
maxillary part denture - resin
mandibular part denture - resin
maxillar part denture - cst mtl
mandibular part denture - mtl
removable unti partial denture
adjust comp dent - maxillary
adjust comp dent - mandibular
adj partial denture - maxillary
adj partial denture - mandibular
repair broken comp dent base
replace teeth - dent/per tooth
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth - per tooth
add tooth to partial denture
add clasp to partial denture
rebase comp maxillary denture
rebase comp mandibular denture
rebase maxillary partial denture
rebase mandibular partial denture
reline comp max dent (chair)
reline mandibular dent (chair)
reline max part denture (chair)
reline partial dent (chair)
reline comp maxillary denture
reline comp mandibular denture
reline maxillary partial denture
reline mandibular partial denture
interim comp dent - mandibular
interim part denture - maxillary
interim part denture - mandibular
tissue conditioning - maxillary
tissue conditioning - mandibular
precision attachment by report
recement fixed partial denture
extraction single tooth
coronal remnants-primary tooth
extraction each additional tooth
root removal-exposed roots
extraction – erupted tooth/exposed root
surgical removal erupted tooth
removal impacted tooth - soft
remove impacted tooth - part bony
remove impact tooth - comp bony
removal of impacted tooth - bony
surg remove residual roots
oroantral fistula closure
Fee
$258.47
$307.79
$437.86
Code
D7261
D7270
D7280
D7281
D7282
$271.20
$340.98
$442.14
$149.66
$114.77
$123.31
$73.10
$63.75
$61.26
$25.55
$627.50
$627.50
$703.99
$703.99
$586.72
$586.72
$688.74
$688.74
$306.09
$34.02
$34.02
$34.02
$34.02
$90.11
$68.90
$62.94
$72.30
$73.99
$68.90
$81.64
$108.80
$261.85
$261.85
$261.85
$261.85
$144.59
$144.59
$132.65
$132.65
$202.37
$202.37
$171.74
$171.74
$322.78
$289.09
$289.09
$72.30
$72.30
$14.80
$39.08
$60.70
$48.36
$54.00
$70.63
$70.92
$108.80
$133.47
$170.05
$199.00
$246.62
$108.80
$255.08
D7283
D7285
D7286
D7290
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
Description
primary closure of a sinus perforation
tooth reimplantation - accident
surg exp impacted tooth - ortho
surg exposure of impacted or unerupted
tooth
mobilization of erupted or malpositioned
tooth to aid eruption
placement of device to facilitate eruption of
impacted tooth
biopsy of oral tissue - hard
biopsy of oral tissue - soft
surgical reposition of teeth
alveoloplasty w/ extract/quad
alveoloplasty in conjunction with
extractions- one to three teeth or tooth
spaces
alveoloplasty - per quadrant
alveoloplasty not in conjunction with
extractions-one
excision benign lesion – 1.25 cm
excision benign lesion ->1.25 cm
excision of benign lesion, complicated
excision malignant lesion-1.25 cm
excision malignant lesion- >1.25 cm
excision of malignant lesion, complicated
excision malignant tumor-1.25 cm
excision malignant tumor->1.25 cm
removal odontogenic cyst-1.25 cm
removal odontogenic cyst->1.25 cm
removal nonodontogenic cyst-1.25 cm
removal nonodontogenic cyst->1.25 cm
destruction of lesion(s) by physical or
chemical method
removal of lateral exotosis-(maxilla of
mandible)
removal of torus palatinus
removal of torus mandibulars
surgical reduction of osseous tuberosity
radical resection of mand w/ graft
incision/drain abscess - intraoral
incision and drainage of abscess-intraoral
soft tissue-complicated
incision/drain abscess - extraoral
incision and drainage of abscess-extraoral
soft tissue-complicated
removal or foreign body
removal of foreign bodies
partial ostectomy/sequestrectomy
maxillary sinusotomy
max-open reduction – immobilized
max- closed reduction – immobilized
mand-open reduction immobilized
mand-closed reduction-immobilized
malar/zygo arch –open reduction
malar/zygo arch –closed reduction
alveolus-closed reduction
alveolus- open reduction
facial bones-complicated reduction
max-open reduction-compound
max-closed reduction – compound
mand – open reduction-compound
mand- closed reduction-compound
malar/zygo-open reduction- compound
malar/zygo-closed reduction-compound
alveolus-open reduction-stablization
alveolus-closed reduction-stabliztion
facial bones-complicated reduction
open reduction-dislocation
closed reduction-dislocation
121001 AZ Maricopa & UFC MA MC
D-1-2
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$255.08
$246.62
$183.67
$110.57
$110.57
$45.05
$130.10
$130.07
$124.96
$129.28
$81.64
$170.05
$113.08
$90.11
$199.79
$233.80
$178.60
$263.63
$276.36
$174.32
$259.35
$129.28
$165.78
$94.37
$124.93
$60.45
$201.49
$282.07
$443.26
$229.69
$2,780.47
$60.45
$201.49
$108.80
$221.64
$74.96
$92.69
$153.13
$294.42
$1,410.38
$1,007.42
$1,718.26
$886.53
$1,007.42
$685.05
$276.44
$1,390.24
$2,296.91
$1,571.57
$963.09
$1,652.16
$1,039.65
$1,511.13
$1,043.69
$1,007.42
$584.31
$2,893.30
$1,442.62
$124.93
Code
D7830
D7840
D7850
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D8010
D8020
D8030
Description
manipulation under anesthesia
condylectomy
surgical disectomy-w/ or w/o implant
synovectomy
myotomy
joint reconstruction
arthrotomy
arthroplasty
arthrocentesis
non-arthroscopic lysis and lavage
arthroscopy-diagnosis, with or without
biopsy
arthroscopy-surgical: lavage and lysis o
arthroscopy-surgical: disc repositioning
arthroscopy-surgical: synovectomy
arthroscopy-surgical: discectomy
arthroscopy-surgical: debridement
occlusal orthotic appliance
unspecified tmd therapy, by report
suture small wounds up to 5 cm
complicated suture up to 5 cm
complex suture - more than 5 cm
osteoplasty-orthognathic
osteotomy-ramus, closed
osteotomy-mandibular rami with bone
graft, includes obtaining the graft
osteotomy-segmented or subapical-per sex
osteotomy-body of mandible
lefort I (maxilla-total)
lefort I (maxilla-segmented)
lefort II or III (osteoplasty of
lefort II or III -with bone graft
osseous, osteoperiosteal, periosteal, or
repair soft/hard tissue defect
frenulectomy - separate proc
frenuloplasty
excise hyperplastic tiss/arch
excision pericoronal gingiva
surgical reduction of fibous tuberosity
sialolithotomy
excision of salivary gland-by report
sialodochoplasty
closure of salivary fistula
emergency tracheotomy
coronoidectomy
limited orthodontic treatment or the
primary dentition
limited orthodontic treatment or the
transitional dentition
limited orthodontic treatment or the
adolescent dentition
Fee
$189.40
$1,833.50
$1,672.31
$2,087.37
$1,094.46
$2,189.72
$431.18
$2,189.72
$132.98
$241.78
Code
D8040
D8050
D8060
D8070
D8080
D8090
$374.77
$979.21
$979.21
$1,323.34
$1,323.34
$2,189.72
$268.38
$200.68
$56.41
$95.12
$221.64
$1,007.42
$2,780.47
$2,780.47
$2,333.18
$2,518.55
$2,812.70
$2,574.96
$3,222.92
$3,344.62
$721.32
$729.37
$117.67
$117.67
$122.50
$59.64
$100.75
$157.16
$608.48
$443.26
$165.22
$294.17
$1,027.57
D8210
D8220
D8660
D8670
D8680
D8690
D8692
D8693
D9110
D9120
D9210
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9610
D9612
$238.08
$238.08
D9920
D9930
D9940
D9951
Description
limited orthodontic treatment or the adult
dentition
interceptive orthodontic treatment of the
primary dentition
interceptive orthodontic treatment of the
transitional dentition
comprehensive orthodontic treatment of the
transitional dentition
comprehensive orthodontic treatment of the
adolescent dentition
comprehensive orthodontic treatment of the
adult dentition
removable appliance therapy
fixed appliance therapy
pre-orthodontic visit
periodic orthodontic treatment visit
orthodontic retention (removal of
appliances, construction, and placement of
retainers)
orthodontic treatment (alternative billing to
contracted fee)
replacement of lost or broken retainer
rebonding or recementing and/or repair of
fixed retainer
palliative treatment
fixed partial denture sectioning
local anesthesia w/o operative or surgical
procedure
deep sedation/general anesthesia - 1st 30
min
deep sedation/general anesthesia - each 15
min
analgesia/anxiolysis/inhalation of nitrous
oxide
iv conscious sedation/analgesia - 1st 30 min
iv conscious sedation/analgesia - each 15
min
non-intravenous conscious
sedation/analgesia
consultation
house/extended care facility call
hospital call
office visit for observation
office visit after regularly scheduled hours
therapeutic drug injection - by report
therapeutic parenteral drugs 2 +
administrations, different medications
behavior management - by report
treatment of complications - post surgical by report
occlusal guard - by report
occlusal adjustment - limited
$238.08
121001 AZ Maricopa & UFC MA MC
D-1-3
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
Fee
$238.08
$1,105.33
$1,105.33
$2,210.68
$2,486.13
$2,572.87
$259.35
$284.82
$38.29
$112.26
$170.05
$55.29
$110.57
$39.08
$48.44
$44.25
$8.54
$117.67
$54.80
$21.28
$113.08
$32.32
$51.02
$33.13
$38.29
$68.02
$23.77
$53.59
$16.12
$25.55
$29.74
$23.77
$153.05
$41.67
THIS PAGE INTENTIONALLY LEFT BLANK
121001 AZ Maricopa & UFC MA MC
D-1-4
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
MEDICARE REQUIREMENTS
Provider agrees to the following terms and conditions as they pertain to services rendered to Members enrolled in an
applicable Medicare Advantage Plan. Since the Agreement between Provider and DentaQuest, in whole or in part,
relates to services provided to Medicare Advantage Members, you are required by Centers for Medicare and
Medicaid Services (“CMS”), contracted Plan, and DentaQuest, to agree to and comply with the following
requirements.
For purposes of this Medicare Requirements Attachment, reference to “Provider” means the individual or entity
identified as a named party to the Agreement, its employees, contractors and/or subcontractors and those individuals
or entities performing administrative services for or on behalf of Provider and/or any of the above referenced
individuals or entities performing services related to the Agreement. Provider acknowledges that the requirements
contained in this Attachment shall apply equally to the above referenced individuals or entities and that Provider’s
agreements with such individuals or entities shall contain the applicable Medicare requirements set forth in this
Attachment. In the event of a conflict between any provision in this Attachment and such agreement, this
Attachment will control.
Except as specifically amended hereby, the terms and conditions of the Agreement remain the same. In the event of
a conflict between the Agreement and this Attachment, this Attachment will control with respect to Members of
Medicare Advantage Plans.
1. Compliance with Law. Provider acknowledges that payment received for providing Covered Services to
Members under the Agreement, in whole or in part, are deemed to be federal funds subject to all laws and
regulations applicable to recipients of federal funds. As such, Provider agrees to comply with all applicable
Medicare laws, rules and regulations, reporting requirements, CMS instructions, and applicable requirements of the
contract between Plan and CMS (the “Medicare Contract”) and with all other applicable state and federal laws and
regulations, as may be amended from time to time, including, without limitation: (1) Federal laws and regulations
designed to prevent or ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of
Federal criminal law, the False Claims Act (31 U.S.C. 3729 et. seq.), and the anti-kickback statute (section
1128B(b)) of the Act); and (2) the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)
administrative simplification rules at 45 CFR parts 160, 162, and 164. [42 C.F.R. § 422.504(h)].
2. Medicare Advantage Member Privacy and Confidentiality. Provider agrees to comply with all state and
federal laws, rules and regulations, Medicare program requirements, and/or requirements in the Medicare Contract
regarding privacy, security, confidentiality, accuracy and/or disclosure of records (including, but not limited to,
medical records), personally identifiable information and/or protected health information and enrollment
information including, without limitation: (1) HIPAA and the rules and regulations promulgated thereunder, (2) 42
C.F.R. § 422.504(a)(13), and (3) 42 C.F.R. § 422.118; (iv) 42 C.F.R. § 422.516 and 42 C.F.R. § 422.310 regarding
certain reporting obligations to CMS. Provider also agrees to release such information only in accordance with
applicable state and/or federal law or pursuant to court orders or subpoenas.
3. Audits; Access to and Maintenance of Records. Provider shall permit inspection, evaluation and audit directly
by DentaQuest, Plan, the Department of Health and Human Services (DHHS), the Comptroller General, the Office
of the Inspector General, the General Accounting Office, CMS and/or their designees, and as the Secretary of the
DHHS may deem necessary to enforce the Medicare Contract, physical facilities and equipment and any pertinent
information including books, contracts (including any agreements between Provider and its employees, contractors
and/or subcontractors providing services related to the Agreement), documents, papers, medical records, patient care
documentation and other records and information involving or relating to the provision of services under the
Agreement, and any additional relevant information that CMS may require (collectively, “Books and Records”). All
Books and Records shall be maintained in an accurate and timely manner and shall be made available for such
inspection, evaluation or audit for a time period of not less than ten (10) years, or such longer period of time as may
be required by law, from the end of the calendar year in which expiration or termination of this Agreement occurs or
from completion of any audit or investigation, whichever is greater, unless CMS, an authorized federal agency, or
such agency’s designee, determines there is a special need to retain records for a longer period of time, which may
include but not be limited to: (i) up to an additional six (6) years from the date of final resolution of a dispute,
allegation of fraud or similar fault; or (ii) completion of any audit should that date be later than the time frame(s)
Medicare Requirements
1
Current Dental Terminology © 2012 American Dental Association. All rights reserved.
indicated above; (iii) if CMS determines that there is a reasonable possibility of fraud or similar fault, in which case
CMS may inspect, evaluate, and audit Books and Records at any time; or (iv) such greater period of time as
provided for by law. Provider shall cooperate and assist with and provide such Books and Records to DentaQuest,
Plan and/or CMS or its designee for purposes of the above inspections, evaluations, and/or audits, as requested by
CMS or its designee and shall also ensure accuracy and timely access for Members to their medical, health and
enrollment information and records. Provider agrees and shall require its employees, contractors and/or
subcontractors and those individuals or entities performing administrative services for or on behalf of Provider
and/or any of the above referenced individuals or entities: (i) to provide DentaQuest, Plan and/or CMS with timely
access to records, information and data necessary for: (1) Plan to meets its obligations under its Medicare
Contract(s); and/or (2) CMS to administer and evaluate the MA program; and (ii) to submit all reports and clinical
information required by the Plan under the Medicare Contract. [42 C.F.R. § 422.504(e)(4), (h), (i)(2), and (i)(4)(v).]
In accordance with applicable law: (1) nothing in this agreement or any other agreement shall be construed to limit:
(a) the authority of DentaQuest or the Plan to ensure participation in and compliance with its quality assurance,
utilization management, member grievance and other systems and procedures; (b) the DHHS’ authority to monitor
the effectiveness of the Plan’s systems and procedures, or to require the Plan to take prompt corrective action
regarding quality of care or Member appeals, grievances and complaints; (c) DentaQuest or Plan’s authority to
sanction or terminate a provider found to be providing inadequate or poor quality care or failing to comply with
DentaQuest or Plan’s systems, standards or procedures; and (2) Provider shall participate and abide by the decisions
of DentaQuest and/or Plan’s medical policy, quality assurance, medical management, utilization review, member
grievance and Medicare’s appeal system.
Where applicable, Provider will participate in the collection and submission of data to CMS which includes, but is
not limited to the following: (a) impatient hospital data for discharges; (b) physician, outpatient hospital skilled
nursing facility and home health agency data; and (c) all other data CMS deems necessary. Provider shall certify the
accuracy of he data that is collected and submitted to CMS where applicable.
4. Prompt Payment of Claims. DentaQuest and/or Plan and/or Provider, as applicable, agree to process and pay or
deny claims for Covered Services within thirty (30) calendar days of receipt of such claims in accordance with the
Agreement. [42 C.F.R. § 422.520(b).]
5. Hold Harmless of Members. Provider hereby agrees: (i) that in no event, including but not limited to, nonpayment by DentaQuest or Plan, DentaQuest or Plan’s determination that services were not Medically Necessary,
DentaQuest or Plan insolvency, or breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against a Member for amounts that are
the legal obligation of DentaQuest or Plan; and (ii) that Members shall be held harmless from and shall not be liable
for payment of any such amounts. Provider further agrees that this provision (a) shall be construed for the benefit of
Members; (b) shall survive the termination of this Agreement regardless of the cause giving rise to termination, and
(c) supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and
Members, or persons acting on behalf of a Member. [42 C.F.R. § 422.504(g)(1)(i) and (i)(3)(i).]
Provider may notify a Member that certain medical services have been determined to be non-Covered Services
according to the terms of the Plan and may, if the Member desires, make independent financial arrangements in
advance, with written documentation thereof, and collect from such Member for such non-Covered Services. In the
event that any charges for services which are determined to be non-Covered Services are billed by Provider to
DentaQuest, Plan or to a Member who has not agreed in advance in writing to independent financial arrangements
and payment is made by DentaQuest, Plan or Member, Provider shall immediately, upon request by DentaQuest,
Plan and/or Member, refund to DentaQuest, Plan or Member the full amount collected by Provider attributable to
non-Covered Service.
As required by 42 C.F.R. § 1001.952(m)(1)(i), in the case of services furnished to Members, Provider shall not
claim payment in any form from CMS or from any other agency of the United States or from any state for items and
services furnished in accordance with the Agreement, except as may be approved by CMS or a State agency, nor
shall Provider otherwise engage in any shifting of costs or seek increased payments from the Medicare Advantage
Program or any State health care program as a result of furnishing such services to Members.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
6. Accountability. DentaQuest and Provider hereby acknowledge and agree that Plan shall oversee the provision of
services by Provider and DentaQuest and shall be accountable under the Plan’s Medicare Contract for services
provided to Members under the Agreement regardless of the provisions of the Agreement or any delegation of
administrative activities or functions to Provider under the Agreement. [42 C.F.R. § 422.504(i)(1); (i)(4)(iii); and
(i)(3)(ii).]
7. Delegated Activities. Provider acknowledges and agrees that to the extent DentaQuest, in its sole discretion,
elects to delegate any administrative activities or functions to Provider, Provider understands and agrees that: (i)
Provider may not delegate, transfer or assign any of Provider’s obligations under the Agreement and/or any separate
delegation agreement without DentaQuest’s prior written consent; and (ii) Provider must demonstrate, to
DentaQuest’s satisfaction, Provider’s ability to perform the activities to be delegated and the parties will set out in
writing: (1) the specific activities or functions to be delegated and performed by Provider; (2) any reporting
responsibilities and obligations pursuant to DentaQuest’s or Plan’s policies and procedures and/or the requirements
of the Medicare Contract; (3) monitoring and oversight activities by DentaQuest or Plan including without limitation
review and approval by DentaQuest or Plan of Provider’s credentialing process, as applicable, and audit of such
process on an ongoing basis; and (4) corrective action measures, up to and including termination or revocation of the
delegated activities or functions and reporting responsibilities if CMS or DentaQuest or Health Plan determines that
such activities have not been performed satisfactorily. [42 C.F.R. § 422.504(i)(3)(iii); 422.504(i)(4)(i)-(v).]
The parties agree, notwithstanding anything set forth in the Agreement, that the Plan oversees and is accountable to
CMS for any functions or responsibilities that are described in the CMS regulations.
8. Compliance with DentaQuest and Health Plan Policies and Procedures. Provider shall comply with all
policies and procedures of DentaQuest and Plan including, without limitation, written standards for the following:
(a) timeliness of access to care and member services; (b) policies and procedures that allow for individual medical
necessity determinations (e.g., coverage rules, practice guidelines, payment policies); (c) provider consideration of
Member input into Provider’s proposed treatment plan; and (d) Plan’s compliance program which encourages
effective communication between Provider and Plan’s Compliance Officer and participation by Provider in
education and training programs regarding the prevention, correction and detection of fraud, waste and abuse and
other initiatives identified by CMS. The aforementioned policies and procedures are identified in DentaQuest and
Plan Provider Manuals which are incorporated herein by reference and may be amended from time to time by
DentaQuest or Plan. [42 C.F.R. § 422.112; 422.504(i)(4)(v); 42 C.F.R. § 422.202(b); 42 C.F.R. § 422.504(a)(5); 42
C.F.R. § 422.503(b)(4)(vi)(C) & (D) & (G)(3).]
Provider shall report in writing to Plan within thirty calendar days of Provider’s knowledge any and all civil
judgments and “other adjudicated actions or decisions” against Provider related to the delivery of any health care
item or service (regardless of whether the civil judgment or other adjudicated action or decision is the subject of a
pending appeal). “Other adjudicated actions or decisions” means formal or official final actions taken against a
health care provider by a federal or state governmental agency or a health plan, which include the availability of a
due process mechanism, and are based on acts or omissions that affect or could affect the payment, provision, or
delivery of a health care item or service. An action taken following adequate notice and hearing requirement that
meets the standards of due process set out in section 412(b) of the Health Care Quality Improvement Act (42 U.S.C.
§ 11112(b)) also would qualify as a reportable action under this definition. The fact that Provider elects not to use
the due process mechanism provided by the authority bringing the action is immaterial, as long as such a process is
available to the subject before the adjudicated action or decision is made final.
9. Continuation of Benefits. Provider agrees that except in instances of immediate termination by DentaQuest or
Plan for reasons related to professional competency or conduct and upon expiration or termination of the
Agreement, Provider will continue to provide Covered Services to Members as indicated below and to cooperate
with DentaQuest or Plan to transition Members to other participating Providers in a manner that ensures medically
appropriate continuity of care. In accordance with the requirements of the Medicare Contract, DentaQuest’s or
Plan’s accrediting bodies and applicable law and regulation, Provider will continue to provide Covered Services to
Members after the expiration or termination of the Agreement, whether by virtue of insolvency or cessation of
operations of DentaQuest or Health Plan, or otherwise: (i) for those Members who are confined in an inpatient
facility on the date of termination until discharge; (ii) for all Members through the date of the applicable Medicare
Contract for which payments have been made by CMS to DentaQuest or Plan; and (iii) for those Members
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.
undergoing active treatment of chronic or acute medical conditions as of the date of expiration or termination
through their current course of active treatment not to exceed ninety (90) days unless otherwise required by item (ii)
above. [42 C.F.R. 422.504(g)(2) & (3).]
10. Physician Incentive Plans. The parties agree: (i) that nothing contained in the Agreement nor any payment
made by DentaQuest or Plan to Provider is a financial incentive or inducement to reduce, limit or withhold
Medically Necessary services to Members; and (ii) that any incentive plans between DentaQuest or Plan and
Provider and/or between Provider and its employed or contracted physicians and other health care practitioners
and/or providers shall be in compliance with applicable state and federal laws, rules and regulations and in
accordance with the Medicare Contract. Upon request, Provider agrees to disclose to DentaQuest or Plan the terms
and conditions of any “physician incentive plan” as defined by CMS and/or any state or federal law, rule or
regulation. [42 C.F.R. § 422.208.]
11. Termination. Notwithstanding any provision regarding termination, no termination of this Agreement without
cause or requested by Provider shall be effective unless made in advance in writing to DentaQuest, not less than
ninety (90) days prior to the anniversary date of the Agreement. DentaQuest, the Plan or its designee may terminate
Provider from this Product upon ninety (90) days advance written notice to Provider. If in DentaQuest or Plan’s
judgment, Provider has failed to cooperate with and abide by the decisions of DentaQuest or Plan’s medical policy,
quality assurance, medical management, utilization review, member grievance and Medicare’s appeal systems, or is
found to be harming Members, or if the continuation or participation negatively effects patient care, Provider’s
participation in this Product may be terminated. Nothing set forth herein shall limit the ability of the Plan to delegate
all or a portion of these functions. DentaQuest or Plan hereby agrees to provide notice to Provider when DentaQuest
or Plan denies, suspends, or terminates the Agreement with Provider and include: (a) the reason for the action, (b)
the standards and profiling data DentaQuest or Plan used to evaluate Provider, (c) the numbers and mix of health
care professionals needed for DentaQuest or Plan to provide adequate access to services, and (d) Provider’s right to
appeal the action and the timing for requesting a hearing.
12. Treatment Standards. Provider agrees to provide, in a manner consistent with professionally recognized
standards of health care, all benefits covered by the Plan. Provider shall provide Covered Services to Members in
accordance with the same standards and within the same time frames as generally provided by Provider to other
patients that are not Members and to not differentiate or discriminate in the treatment of or in the quality of services
delivered to Members on the basis of age, race, color, national origin, religion, handicap, ancestry or marital status,
any factor that is related to health status, or participation in the Medicare Program. Factors related to health status
include, but are not limited to the following: (a) medical condition, including mental as well as physical illness; (b)
claims experience; (c) receipt of health care; (d) medical history; (e) genetic information; (f) evidence of
insurability, including conditions arising out of acts of domestic violence; and (g) disability.
14. Credentialing. To participate in any product offered to Medicare Members, Provider must meet the
credentialing standard established by DentaQuest and Plan.
15. Exclusion. Provider shall not employ or contract for the provision of health care, utilization review, medical
social work, or administrative services with any individual excluded from participation in Medicare under section
1128 and 1128A of the Social Security Act. Provider hereby certifies that no such excluded person currently is
employed by or under contract with Provider relating to the furnishing of these services to Members. Providers that
are facilities, including Participating Hospitals, must be Medicare certified. All other Providers must be Medicare
participating providers. Participating Providers shall notify DentaQuest upon any change in such status.
16. Initial Assessment. As applicable, Provider shall cooperate with Plan in furnishing an initial assessment of
new Members’ heath care needs within 90 days of their enrollment.
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Current Dental Terminology © 2012 American Dental Association. All rights reserved.