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The document provides instructions for use and sets documentation expectations for adjudicating claims, linking required clinical record evidence to specific CDT codes. 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\nHealthplex  \nDental Claim Review Guideline  \nDental Claim Review Guidelines  \n(Comprehensive & Limited Plans)  \nGuideline Number: DRG042 .20  \nEffective Date: January 1, 2026  \nTable of Contents  \n•  Instructions for Use .........................................................  1  \n•  Documentation Requirements ........................................ 2  \n•  Diagnostic ....................................................................... 2  \n•  Preventive ....................................................................... 5  \n•  Restorative...................................................................... 6  \n•  Endodontics ..................................................................  14  \n•  Periodontics ..................................................................  17  \n•  Removable Prosthodontics........................................... 20  \n•  Implants ........................................................................ 24  \n•  Fixed Prosthodontics .................................................... 30  \n•  Oral and Maxillofacial Surgery...................................... 35  \n•  Orthodontics ................................................................. 40  \n• Adjunctive General Services ........................................ 41  \n•  Guideline History/Revision Information ........................ 43  \n•  Coverage Criteria / Dental Policies............................... 44  \nInstructions for Use  \nThis Utilization Review Guideline is designed to provide guidance for the adjudication of claims for Healthplex standard and Limited Dental Plans , and includes only the CDT codes for which clinical documentation is required with related links to the policies and coverage guidelines approved by the Dental Clinical Policy and Technology Committee. Before using this guideline, check the member specific benefit plan document and any applicable federal or state mandates. Healthplex reserves the right to modify its Policies and Guidelines as necessary. This Utilization Review Guideline is provided for informational purposes. It does not constitute medical advice.  \nNotes:  \n Dental Clinical Policies and Dental Coverage Guidelines are embedded at the end of this document starting at page  \n59. These specific policies are listed in alphabetically. You may use the Table of Contents link to access “Summary of all Coverage Criteria/ Dental Policies”.  \n For further CDT code description and information, refer to the most current version of the CDT Dental Procedures Codes released by the American Dental Association (ADA) .  \nDocumentation Requirements  \nA comprehensive, detailed medical record is key to promoting quality care and improving patient safety. For the services outlined in the grid below, specific documentation that is needed in order to make a determination on coverage is listed in the Documentation Requirements column. Submit this information with your request for coverage.  \nTo ensure the best health outcomes for our members, we may periodically require providers to submit documentation for services that do not have specific documentation requirements listed below.  \nDiagnostic  \n\n| CDT Code | Code Description | Documentation Requirements | Related Dental Policy |\n| --- | --- | --- | --- |\n| Clinical Oral Evaluations |  |  |  |\n| D0120 | Periodic oral evaluation – established patient | N/A | N/A |\n| D0140 | Limited oral evaluation – problem focused | N/A | N/A |\n| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | N/A | N/A |\n| D0150 | Comprehensive oral evaluation – new or established patient | N/A | N/A |\n| D0160 | Detailed and extensive oral evaluation – problem focused, by report | N/A | N/A |\n| D0170 | Re-evaluation – limited, problem focused (established patient; not post-operative visi","cbCaidZiwHazrteR","https://ap.wps.com/l/cbCaidZiwHazrteR","pdf",2935316,263,"English","# Instructions for Use\n# Documentation Requirements\n# Diagnostic\n# Preventive\n# Restorative\n# Endodontics\n# Periodontics\n# Removable Prosthodontics\n# Implants\n# Fixed Prosthodontics\n# Oral and Maxillofacial Surgery\n# Orthodontics\n# Adjunctive General Services\n# Guideline History/Revision Information\n# Coverage Criteria / Dental Policies","[{\"question\":\"What is the purpose of the Healthplex Dental Claim Review Guideline?\",\"answer\":\"It provides guidance for adjudicating claims for Healthplex standard and Limited Dental Plans and specifies which CDT codes require clinical documentation.\"},{\"question\":\"Where can embedded Dental Coverage Guidelines and policies be found?\",\"answer\":\"They are embedded at the end of the document starting at page 59, listed alphabetically, with a table-of-contents link to a summary.\"},{\"question\":\"What should providers submit for services listed in the documentation grid?\",\"answer\":\"Providers should submit the specific information listed in the Documentation Requirements column for the services being requested to support the coverage determination.\"}]","Healthplex - Dental Claim Review Guidelines - Comprehensive & Limited Plans - DRG042 - Documentation guideline | PDF",1790431652,663]