Dental Services

Capstone Health Plan covers dental services provided by a licensed dentist or dental hygienist to Members within certain limits based on Member age. Enrolled Members have direct access to dental providers. When the Member presents to the dentist, the dentist office should call Capstone Health Plan to verify eligibility and verify prior-authorization when appropriate.

Dental Services that Do Not Require Prior Authorization

Routine dental care for children age 0-20 is covered every six months and does not require prior authorization. Routine care includes the following codes:

D0120 D1120
D0150 D1201
D0220 D1203
D0230 D1204
D0272 D1205
D0274 D9230
D0330 D9248
D1110 D9920

Dental Services That Require Prior Authorization

  1. Dental care for Members age 0-20 that is not "routine care."
  2. Dental care for Members 21 years of age or older. Only the following services for adults are covered:
    • Emergency dental services, which include:
      1. Relief of severe pain accompanying an oral or maxillofacial condition, limited to immediate palliative treatment, but including extractions when professionally indicated.
      2. Initial treatment for acute infections.
      3. Immediate and palliative procedures for acute craniomandibular problems and for traumatic injuries to teeth, bone and soft tissue.
      4. Laboratory and preoperative procedures, including examinations and radiographs.
      5. Appropriate anesthesia for optimal patient management.
    • Medically necessary dentures.
    • Pre-transplant dental services.
Capstone Health Plan