Blue Cross Blue Shield FEP Dental Brochure - 2022

Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic
Additional Procedures Covered as Basic Services
D9110 Palliative treatment of dental pain – minor procedure- Not covered the same day as final treatment

D9310 Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

D9311 Consultation with a medical health care professional

D9440 Office visit after regularly scheduled hours

Class A Basic Notes:
  • All exams, oral evaluations and treatments such as fluorides are combined under one limitation under the plan. For example, periodic oral exam (D0120), oral evaluations (D0140), and comprehensive oral exam (D0150, D0180) are combined and limited to two examinations per year. If you have a periodic oral evaluation and a limited oral exam, both services are combined, so that not more than the maximum allowable expense and limitation are paid.
  • Prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation:
    • Limit 3 during the calendar year for any combination of D1110, D1120, and D4346, age 13 and under will be processed as D1120 and age 14 and over will be processed as D1110.
  • One comprehensive evaluation per provider’s office; additional comprehensive evaluations will be processed as a periodic evaluation
  • 14 or more films on the same date of service will be processed as a D0210 (complete set of radiographic images). Bitewing x-rays with the same date of service as a Panoramic radiographic image will be processed as a D0210.
  • Certified translation or sign-language services per visit according to Federal Regulation