Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Endodontic Services Service includes all necessary radiographs or views needed for endodontic treatment. Teeth must be in occlusion, periodontally sound, needed for function and have good long term prognosis. Emergency services for pain do not require prior authorization. Service requires prior authorization and will not be considered for teeth that are not in occlusion or function and have poor long term prognosis. Endodontic service to include: Therapeutic pulpotomy for primary and permanent teeth Pulpal debridement for primary and permanent teeth Partial pulpotomy for apexogensis Pulpal therapy for anterior and posterior primary teeth Endodontic therapy and retreatment
Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Endodontic Services Service includes all necessary radiographs or views needed for endodontic treatment. Teeth must be in occlusion, periodontally sound, needed for function and have good long term prognosis. Emergency services for pain do not require prior authorization. Service requires prior authorization and will not be considered for teeth that are not in occlusion or function and have poor long term prognosis. Endodontic service to include: Therapeutic pulpotomy for primary and permanent teeth Pulpal debridement for primary and permanent teeth Partial pulpotomy for apexogensis Pulpal therapy for anterior and posterior primary teeth Endodontic therapy and retreatment
HMOContract2018P.docx