Allowable Benchmark Plan Base benchmark plan specifically excludes oral surgery to treat a exclusion fractured jaw, and orognathic surgery. Oral Surgery and (Cont’d) Periodontics WAC Required Plan must periodontic services in a manner substantially equal to Periodontic See, the base benchmark plan including, at a minimum: also, Services WAC WAC Periodontal scaling and root planning once per quadrant in a period for ages thirteen and older; WAC Periodontal maintenance once per quadrant in a period for ages thirteen and older; Benchmark plan Complex periodontal procedures (osseous surgery including flap entry and closure and mucogingivoplastic surgery) limited to once per Member per quadrant in a five-year period;
Oral Surgery and (Cont’d) Allowable exclusion Benchmark Plan Base benchmark plan specifically excludes oral surgery to treat a fractured jaw, and orognathic surgery. Periodontics Required Periodontic Services WAC See, also, WAC Plan must periodontic services in a manner substantially equal to the base benchmark plan including, at a minimum: WAC Periodontal scaling and root planning once per quadrant in a period for ages thirteen and older; WAC Periodontal maintenance once per quadrant in a period for ages thirteen and older; Benchmark plan Complex periodontal procedures (osseous surgery including flap entry and closure and mucogingivoplastic surgery) limited to once per Member per quadrant in a five-year period;
cklist-forms-2018-all-filers-ind-embedded-pediatric-dental-ehbs.docx