| INSURANCE Information | ||
|---|---|---|
| Insurance Company | ||
| Address | ||
| City | ||
| State | ||
| Zip Code | ||
| Phone # | ||
| Electronic Payer ID | ||
| Group/Employer/Plan Name | ||
| Group # | ||
| Last Verified Date | ||
| Ins Rep Name | ||
| GENERAL Information | ||
| Renewal Type | ||
| Contract Year Anniversary (MM/DD) | ||
| CATEGORY BREAKDOWN | ||
| Individual Maximum $ | ||
| Individual Maximum $ | ||
| Family Maximum $ | ||
| Individual Deductible $ | ||
| Individual Deductible $ | ||
| Individual Deductible $ | ||
| Individual Deductible $ | ||
| Family Deductible $ | ||
| Family Deductible $ | ||
| Preventive %(Type 1)% | ||
| Deductible(Applies) | ||
| Diagnostic %(Type 2)% | ||
| Deductible(Applies) | ||
| Basic %(Type 3)% | ||
| Deductible Applies | ||
| Waiting Period | ||
| Major %(Type 4)% | ||
| Deductible Applies | ||
| Waiting Period | ||
| Missing Tooth Clause | ||
| Crown Replacement Clause | ||
| Bridge Replacement Clause | ||
| Denture Replacement Clause | ||
| ORTHO Coverage | ||
| Ortho %(Type 5)% | ||
| Ortho Maximum $ | ||
| Ortho Deductible | ||
| Ortho Deductible $ | ||
| Ortho Age Limitation | ||
| Ortho Wait Period ? | ||
| Is Periodic Billing Required? | ||
| D7780 - Orthotic Device % | ||
| D8040 - Limited Ortho Adult % | ||
| D8080-Ortho - Invisalign % | ||
| EXAMS AND X-RAYS | ||
| Periodic Exam(D0120) | ||
| Frequency | ||
| Emergency Exam(D0140) | ||
| Frequency | ||
| Comprehensive Exam(D0150) | ||
| Frequency | ||
| Frequency | ||
| Comprehensive Perio Eval (D0180) | ||
| Full Mouth Series -FMX (D0210) | ||
| Frequency | ||
| Frequency | ||
| Shares Frequency with PANO | ||
| Restrictions | ||
| Restrictions | ||
| Periapical X - ray - PAs(D0220) | ||
| Additional PAs(D0230) | ||
| Bite Wing X-rays (D0274) | ||
| Frequency | ||
| Age Limit | ||
| PANORAMIC x - ray(D0330) | ||
| Frequency | ||
| Shares Frequency with FMX | ||
| PREVENTIVE Services | ||
| Prophylaxis-Adult(D1110) | ||
| Frequency | ||
| Frequency | ||
| Prophylaxis-Child(D1120) | ||
| Frequency | ||
| Age Limit | ||
| Fluoride-Varnish(D1206) | ||
| Frequency | ||
| Age Limit | ||
| Fluoride-Excluding Varnish(D1208) | ||
| Sealants (D1351) | ||
| Frequency | ||
| Frequency | ||
| Age Limit | ||
| Restrictions | ||
| Restrictions | ||
| Space maintainers(D1510) | ||
| Frequency | ||
| Frequency | ||
| Age Limit | ||
| Age Limit | ||
| RESTORATIVE Services | ||
| Posterior Composite fillings (D2391) | ||
| Downgrade | ||
| Porcelain or Ceramic Inlay (D2620) | ||
| Downgrade | ||
| Porcelain or Ceramic Onlay (D2642) | ||
| Downgrade | ||
| Crown Porcelain Fused to Hi Noble Metal (D2750) | ||
| Downgrade | ||
| Prosthesis pay at the time of Prep or Seat? | ||
| Prefab SS Crown Primary Tooth (D2930) | ||
| Post & Core in Addition to Crown (D2952) | ||
| Can D2950-D2954 be done same day as a Root Canal? | ||
| ENDODONTIC Services | ||
| Pulp Cap Direct/Indirect (D3110-D3120) | ||
| Pulpal Therapy Anterior Primary (D3220) | ||
| Pulpal Therapy Posterior Primary (D3240) | ||
| Anterior Root Canal (D3310) | ||
| Molar Root Canal (D3330) | ||
| Retreat Molar Endodontics (D3348) | ||
| PERIODONTIC Services | ||
| Gingiv Flap Rtpln 4+T/Per Quad (D4240) | ||
| Gingi Flap Rtpln 1-3t Pr Quad (D4241) | ||
| Clinical Crwn Lngthng Hard Tissue (D4249) | ||
| Periodontal Surgery(D4260) | ||
| Osseous Surgery 1-3t Pr Quad (D4261) | ||
| Is a Periodontal Graft Covered (D4263) | ||
| Describe Restrictions | ||
| Subepithelial Conn Tiss Graft (D4273) | ||
| Soft Tissue Allograft (D4275) | ||
| Provsnl Splinting Extracoronal (D4321) | ||
| Periodontal Scaling/Root Planing (D4341) | ||
| Frequency | ||
| Frequency | ||
| Will multiple quads be paid if done on same visit? | ||
| Will multiple quads be paid if done on same visit? | ||
| Are charting & x-rays required (D4341)? | ||
| Is pre-authorization required (D4341) | ||
| Full Mouth Debridement (D4355) | ||
| Arrestin/Antimicrobial Agent (D4381) | ||
| Perio Maintenance (D4910) | ||
| Frequency | ||
| Frequency | ||
| Share freq with D1110 | ||
| Are Charting & x-rays required (D4910) | ||
| Is active treatment required? (D4910) | ||
| Is active treatment required? (D4910) | ||
| Is active treatment required? (D4910) | ||
| Is active treatment required? (D4910) | ||
| Is active treatment required? (D4910) | ||
| Is active treatment required? (D4910) | ||
| REMOVABLE PROSTHETICS | ||
| Dentures / Partials - Fixed and Removable (D5110-D5226) | ||
| Partial/Denture Adjustment (D5410) | ||
| Restrictions D5410 | ||
| IMPLANTS | ||
| Implant Coverage(D6010) | ||
| Implant Crowns(D6059) | ||
| Downgrade(D6059) | ||
| Bridges-Fixed(D6750) | ||
| Downgraded to Bridge/Partial (D5410 or D6750) | ||
| ORAL SURGERY SERVICES | ||
| Oral surgery-Simple Extractions (D7140) | ||
| Surgical Extractions(D7240) | ||
| Do surgical procedures need to be filed with Medical Ins | ||
| Do surgical procedures need to be filed with Medical Ins | ||
| Ridge Augmentation Covered (D7953) | ||
| Frenulectomy / Frenectomy / Frenotomy (D7960) | ||
| MISCELLANEOUS Services | ||
| Emergency Treatment / Palliative(D9110) | ||
| General Anesthesia-30 Min (D9223) | ||
| Guidelines | ||
| Nitrous Oxide Sedation (D9230) | ||
| Occlusal Guard, By Rpt (9940) | ||
| Frequency | ||
| Bruxism or Osseous Surgery | ||
| Occlusal Adjustment Limited (D9951) | ||
| Comments | ||
| Verified By | ||
| Date Created | ||
| Individual History | ||
| ELIGIBILITY STATUS | ||
| Coverage Status | ||
| Plan | ||
| Effective Date | ||
| Family or Individual Coverage | ||
| HISTORY NOTES | ||
| Benefits Remaining | ||
| Benefits Remaining | ||
| Current Carryover | ||
| Ortho Benefits Remaining | ||
| Deductible Remaining | ||
| Family Deductible Remaining | ||
| Waiting Period Met? | ||
| Last Cleaning | ||
| Last Exam | ||
| Last Bw X-rays | ||
| Last FMX / PAN | ||
| Last Perio Scaling UR | ||
| Last Perio Scaling LR | ||
| Last Perio Scaling UL | ||
| Last Perio Scaling LL | ||
| Last D4910 | ||
| Last D4355 | ||
| Misc.History Given | ||
| Verified by | ||
| Verified Date | ||