Covered Service Prior Authorization Age/ICF-IID required Proc. Description under age age 21 & under age age 21 & Additional Limits Max Code 21 & all over 21 & all over ICF-IID when ICF-IID when residents* allowed residents allowed under under 25.04 25.04 I. DIAGNOSTIC CLINICAL ORAL EXAMINATIONS D0120 Periodic Oral Evaluation YES NO NO Twice per calendar year, but no $30.00 more than once every 150 days. D0140 Limited Oral Evaluation YES YES NO NO Once per episode per provider. $20.00 (Problem Focused) Denturists may also use this code. D0145 Oral Evaluation for a Patient Three Years of Age YES NO NO For members under age 3, twice $20.00 and Counseling with Primary Caregiver per calendar year. Code may not be used for members age 3 and over. Comprehensive Oral Evaluation YES NO NO $55.00 D0160 Detailed and Extensive Oral Evaluation - Problem YES NO NO $25.00 Focused D0170 Re-evaluation Limited, Problem Focused, (established YES NO NO $20.00 – patient, not post-operative D0180 Comprehensive Periodontal Evaluation New or NO NO Not Covered – Established Patient PRE-DIAGNOSTIC SERVICES D0190 Screening of Patient NO NO Not Covered D0191 Assessment of a Patient NO NO Not Covered
Covered Service Age/ICF-IID Prior Authorization required Proc. Code Description under age 21 & all ICF-IID residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 Additional Limits Max I. DIAGNOSTIC CLINICAL ORAL EXAMINATIONS D0120 Periodic Oral Evaluation YES NO NO Twice per calendar year, but no more than once every 150 days. $30.00 D0140 Limited Oral Evaluation (Problem Focused) YES YES NO NO Once per episode per provider. Denturists may also use this code. $20.00 D0145 Oral Evaluation for a Patient Three Years of Age and Counseling with Primary Caregiver YES NO NO For members under age 3, twice per calendar year. Code may not be used for members age 3 and over. $20.00 Comprehensive Oral Evaluation YES NO NO $55.00 D0160 Detailed and Extensive Oral Evaluation - Problem Focused YES NO NO $25.00 D0170 Re-evaluation – Limited, Problem Focused, (established patient, not post-operative YES NO NO $20.00 D0180 Comprehensive Periodontal Evaluation – New or Established Patient NO NO Not Covered PRE-DIAGNOSTIC SERVICES D0190 Screening of Patient NO NO Not Covered D0191 Assessment of a Patient NO NO Not Covered