Change of Benefit Category for Prosthodontics Dental Codes
Posted 1/28/13
Effective March 1, 2013, the following American Dental Association billing codes will be changed from Category B – Basic Restorative Services to Category C – Major Restorative Services: D5410, D5411, D5421, D5422, D5510, D5520, D5610, D5620, D5630, D5640, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, D5751, D5760, and D5761.
SUMMARY SCHEDULE OF COVERED BENEFITS
| NETWORK | NON-NETWORK | |||
|---|---|---|---|---|
| Covered Services (Category) | Calendar Year Deductible | Plan Pays (of Allowed Charges) | Calendar Year Deductible | Plan Pays (of Allowed Charges) |
| Preventive (A) | None | 100% | $25** | 100% |
| Basic Restorative Services (B) | $25* | 85% | $25** | 70% |
| Major Restorative Services (C) | $25* | 60% | $25** | 50% |
| Orthodontia (D) | None | 50% | None | 50% |
*Network Services: There is a $25 calendar year deductible per person for Basic and Major services combined. The calendar year family deductible for Basic and Major services combined is $75.
**Non-Network Services: There is a $25 calendar year deductible per person for Preventive, Basic, and Major services combined. The calendar year family deductible for Preventive, Basic, and Major services combined is $75.
Network and Non-Network deductibles accumulate separately.
If you have questions about eligibility and benefits, please contact HP Administrative Services, LLC at 1-405-416-1800 or toll-free 1-800-782-5218.
Last Modified on 01/29/2013