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Elizabeth M. Whitehorn, Director

Provider Notice Issued 04/30/2021

Date:     April 30, 2021

 

To:       Dental Providers, Federally Qualified Health Centers (FQHCs), EncounterRate Clinics (ERCs), and Rural Health Clinics (RHCs)

 

Re:      Dental Benefit Limitations Amended

 

 

This provider notice serves to inform dental providers that the IllinoisDepartment of Healthcare and Family Services (HFS) will be temporarily amendingbenefit limitations for certain dental services. This change applies to claimsbilled for participants covered under fee-for-service as well as a HealthChoice Illinois managed care plan.

Thefollowing CDT dental code benefit changes are effective for children for datesof service starting May 1, 2021 until the COVID-19 public health emergency nolonger exists.

CDT Code

Description

Age Range/ Tooth #

Temporary Benefit Limitation

D0120

Periodic Oral Examination

 

    0-20

One of (D0120) per 6 Month(s) per patient. Participants are also eligible for one periodic oral evaluation (D0120) performed in a school setting per school year (08/01/XXXX – 07/31/XXXX).  Completion of a mandated school exam form is considered part of the oral examination.

D1120

Prophylaxis – Child

0-20

 

One of (D1120, D4355) per 6 months in an office/mobile setting in addition to one per 6 months in school setting. Removal of plaque, calculus and stains from the tooth surfaces, intended to control local irrational factors.

D1206

Topical Application of Fluoride Varnish

3-20

 

One of (D1206, D1208) per 6 months in an office in addition to one per 6 months in a school setting.

 

D1208

Topical Application of Fluoride (excluding prophylaxis)

3-20

One of (D1206, D1208) per 6 months in an office in addition to one per 6 months in a school setting.

 

D1351

D1351 – Sealant – Per Tooth

5-17

 

Teeth 2, 3, 14, 15, 18, 19, 30, 31

One per 2 years per tooth regardless of place of service. Occlusal surfaces only. Teeth must be caries free. Sealant will not be covered when placed over restorations.

 

Questions regarding this notice may be directed to the Bureau ofProfessional and Ancillary Services at 877-782-5565 for fee-for-service claims,or to the individual HealthChoice Illinois managed careplan.

 

Kelly Cunningham,Administrator
Division of Medical Programs

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