Please read the following information carefully for your procedure frequencies and provisions.
All dental benefits are paid according to the terms of the Master Contract between the Health Plan, Dental Plan and Group Insurance Board. The Uniform Dental Benefits are wholly incorporated in the Master Contract.
This is a list of Uniform Dental Benefits and is based upon the Current Dental Terminology © American Dental Association. Codes are provided as a reference and may be subject to change; plans may substitute alternative codes to provide essentially equivalent coverage.
Dental Plan Administrator: The third party administrator responsible for providing the Uniform Dental Benefit plan under the Group Insurance Board’s program. Delta Dental of Wisconsin is the current Dental Plan Administrator for the Uniform Dental Benefit plan.
Dental Plan: Means all benefits, limitations, and exclusions included in the Uniform Dental Benefit Certificate.
Dental Provider: A dentist or any other person or entity licensed by the state of Wisconsin, or other applicable jurisdiction, to provide one or more Dental Plan benefits.
In-Network Dental Provider: A Dental Provider who has agreed in writing by executing a participation agreement to provide or direct dental care services, supplies, or other items covered under the policy to participants. The Dental Provider’s written participation agreement must be in force at the time of such services, supplies or other items covered under the policy are provided to the participant.
Note that there are no out-of-network benefits available under this Dental Plan.
No payment will be made for a benefit that is not listed.
- Your benefits are based on a calendar year. A calendar year runs from January 1 through December 31.
- During the first year a person is insured, benefits begin on the effective date and continue through December 31 of that year.
- Covered procedures are subject to all plan provisions, procedure and frequency limitations, and/or consultant review.
- X-ray films, periodontal charting and supporting diagnostic data may be requested for health plan review.
- We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be expensive.
- A pre-treatment estimate is not a pre-authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed.
- Note that your medical insurance may provide coverage for some oral surgery. Refer to your medical benefits certificate for additional oral surgery coverage.
The following services are limited under this Dental Plan:
- Oral Exams limited to two per year.
- Full Mouth or Panoramic x-rays limited to once every 60 months.
- Bitewing x-rays limited to one set per year.
- Cleaning of teeth limited to two times per year.
- Fluoride treatment allowed only for a child under age 19, limited to two times per year.
- Sealants allowed only for a child under age 19, and must be applied to non-restored, non-decayed first and second permanent molars, limited to once per tooth per lifetime.
- Routine pediatric dental services as required under federal law.
**Special note on fillings: On anterior (front) teeth, you will have 100% coverage subject to your benefit maximum for both amalgam (silver) and composite/resin (tooth colored) fillings. On posterior (back) teeth, you have 100% coverage subject to your benefit maximum for amalgam (silver) fillings only. If you have a composite/resin (tooth colored) filling on a posterior tooth, you will be responsible for the difference between the amount your provider charges for an amalgam and a composite/resin filling.
The following are not covered services under this Dental Plan:
- Services for injuries or conditions that can be compensated under Workers’ Compensation or Employer Liability laws.
- Services or appliances started prior to the date the patient became eligible for coverage under the State of Wisconsin’s Group Health Insurance Program’s Uniform Dental Benefit.
- Prescription drugs, pre-medications or relative analgesia charges for anesthesia in connection with covered oral surgery procedures.
- Preventive control programs; charges for failure to keep a scheduled visit with a dentist; charges for completion of forms; charges for consultation.
- Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a dentist for treatment in any such facility.
- Charges for treatment of, or services related to, temporomandibular joint dysfunction.
- Services that are determined to be partially or wholly cosmetic in nature.
- Appliances, restorations or procedures for increasing vertical dimension; for restoring occlusion; for correcting harmful habits; for replacing tooth structure lost by attrition; for correcting congenital or developmental malformations, including replacement of congenitally missing teeth, unless restoration is needed to restore normal bodily function; for temporary dental procedures; for implantology techniques or for splints, unless necessary as a result of accidental injury.
- Replacement of lost or broken retainer.
- Treatment by other than a Dental Provider, his or her employees, or his or her agents.
- Dental care injuries or diseases caused by war or act of war, riots or any form of civil disobedience; injuries sustained while committing a felony; injuries intentionally inflicted; injuries or diseases caused by atomic or thermonuclear explosion or by the resulting radiation.
- Claims not submitted to Dental Plan Administrator within 12 months, or if later, as soon as reasonably possible, from the date the procedure was provided.
- Dental procedures in cases where, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained.
- Procedures and services not specifically provided under this Certificate of Coverage and procedures and services excluded by Dental Plan.
- Any oral surgical procedures not specifically listed as a covered benefit or for which coverage exists under Uniform Benefits.
Key Contract Provisions
Covered Services (Examples)
Annual Benefit Max:
$1,000 per participant
Diagnostic / Preventive:
Limited to Periodontal Maintenance
50% (children only)
Ortho Lifetime Max*:
$1,500 per participant
*Lifetime max does not reset when you change health plans
Routine Oral Evaluation - exams are limited to two per year.
Note that comprehensive exams are not done multiple times in a year.
- D0120 Periodic oral evaluation.
- D0145 Oral evaluation for patient under three years of age.
- D0150 Comprehensive oral evaluation – new/established patient or a patient who has been absent from dental care for more than three years; included as one of the two exams per year.
- D0160 Detailed & extensive oral evaluation.
- D0180 Comprehensive perio evaluation – new/established patient; included as one of the two exams per year.
Limited Oral Evaluation
- D0140 Limited oral evaluation - problem focused.
Complete Series or Panoramic Film: limited to one (either D0210 or D0330) once every 60 months.
- D0210 Intraoral - Complete including bitewings.
- D0330 Panoramic radiographic image.
- D0220 Intraoral periapical first radiographic image.
- D0230 Intraoral periapical additional radiographic image.
- D0240 Intraoral occlusal radiographic image.
- D0250 Extraoral first radiographic image.
- D0260 Extraoral each additional radiographic image.
Bitewing Films - limited to one set per year.
- D0270 Bitewing single radiographic image.
- D0272 Bitewings two radiographic images.
- D0273 Bitewings three radiographic images.
- D0274 Bitewings four radiographic images.
- D0277 Vertical bitewings 7 to 8 radiographic images.
Prophylaxis (Cleaning) and Fluoride:
Prophylaxis: D1110, D1120
- D1110 Prophylaxis (cleaning) – Adult; limited to twice per year.
- D1120 Prophylaxis (cleaning) – Child; limited to twice per year.
Fluoride - limited to twice per year up to age 19.
- D1206 Topical application of fluoride varnish.
- D1208 Topical application of fluoride.
- D1351 Sealant - per tooth; limited to once per lifetime up to age 19, primary and permanent molars only.
- D1354 Interim caries arresting medicament application - per tooth; limited to four teeth per benefit period.
Space Maintainers - limited to primary teeth lost prematurely
- D1510 Space maintainer fixed unilateral.
- D1515 Space maintainer fixed bilateral.
- D1520 Space maintainer removable unilateral.
- D1525 Space maintainer removable bilateral.
- D1550 Recementation space maintainer.
- D1555 Removal of fixed space maintainer.
- D1575 Distal shoe space maintainer fixed unilateral.
Evidence-Based Integrated Care Plan ("EBICP"):
The following Evidence-Based Integrated Care Plan (“EBICP”) Benefits are provided under your policy. To participate in EBICP, eligible dental policy enrollees or their Providers are required to set the appropriate health condition indicator online at deltadentalwi.com/state-of-wi or a Delta Dental of Wisconsin representative will assist in setting the EBICP indicator by telephone. The EBICP Periodontal Disease health condition indicator will be automatically updated when non- surgical or surgical periodontal procedures are processed by Delta Dental of Wisconsin. This Amendment supersedes any previous amendment provided to you regarding EBICP.
The EBICP Benefits are as follows:
- With an indicator of surgical or non-surgical treatment of Periodontal Disease, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of surgical or non-surgical treatment of Periodontal Disease, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
- With an indicator of a Diabetes diagnosis, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of Pregnancy, a participant is eligible for one additional dental visit for adult prophylaxis or periodontal maintenance during the pregnancy.
High Risk Cardiac Conditions
- With an indicator for High Risk Cardiac Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. High risk cardiac condition indicators are:
- History of infective endocarditis
- Certain congenital heart defects (such as having one ventricle instead of the normal two)
- Individuals with artificial heart valves
- Heart valve defects caused by acquired conditions like rheumatic heart disease
- Hyper tropic cardiomyopathy which causes abnormal thickening of the heart muscle
- Individuals with pulmonary shunts or conduits
- Mitral valve prolapse with regurgitation (blood leakage)
Suppressed Immune System Conditions
- With an indicator for Suppressed Immune System Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of Suppressed Immune System Conditions, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
Kidney Failure or Dialysis Conditions
- With an indicator for Kidney Failure or Dialysis Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
Cancer Related Chemotherapy and/or Radiation
- With an indicator for Cancer Related Chemotherapy and/or Radiation, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of Cancer Related Chemotherapy and/or Radiation, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
**see note on fillings on page 79 of this certificate.
- D2140 Amalgam filling - one surface.
- D2150 Amalgam filling - two surfaces.
- D2160 Amalgam filling - three surfaces.
- D2161 Amalgam filling – four/more surfaces.
**see note on fillings near the top of this certificate.
- D2330 Resin filling - one surface anterior.
- D2331 Resin filling - two surfaces anterior.
- D2332 Resin filling - three surfaces anterior.
- D2335 Resin filling – four/more surfaces anterior.
- D2390 Resin Crown anterior.
- D2391 Resin filling - one surface posterior; benefits limited.
- D2392 Resin filling - two surfaces posterior; benefits limited.
- D2393 Resin filling - three surfaces posterior; benefits limited.
- D2394 Resin filling – four/more surfaces posterior; benefits limited.
- D2940 Sedative filling; limited to once per lifetime per tooth.
- D2951 Pin retention per tooth; limited to once per tooth.
- D2999 Unspecified restorative procedure by report.
- D4910 Periodontal maintenance.
- D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth after oral evaluation. Coverage is limited to a total of two of the above periodontal procedures per one benefit period in addition to routine cleanings.
Please note that eligible oral surgical procedures are covered under Uniform Medical Benefits when furnished by a covered Dental Provider.
- D9110 Emergency treatment/palliative.
- D9222 Deep sedation/general anesthesia - first 15 minutes.
- D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment.
- D9230 Nitrous oxide sedation.
- D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes.
- D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment.
- D9610 Therapeutic parenteral drug, single administration.
- D9612 Therapeutic parenteral drugs.
- D9910 Application of Desensitizing.
- D9911 Apply desensitizing resin.
- D9930 Treatment of complications.
- D9999 Unspecified adjunctive procedure.
Orthodontic Services - limited to age 19, 50% coverage.
- D8010 Limited orthodontic treatment of primary dentition.
- D8020 Limited orthodontic treatment of transitional dentition.
- D8030 Limited orthodontic treatment of adolescent dentition.
- D8040 Limited orthodontic treatment of adult dentition.
- D8050 Interceptive orthodontic treatment of primary dentition.
- D8060 Interceptive orthodontic treatment of transitional dentition.
- D8070 Comprehensive orthodontic treatment of transitional dentition.
- D8080 Comprehensive orthodontic treatment of adolescent dentition.
- D8090 Comprehensive orthodontic treatment of adult dentition.
- D8660 Pre-orthodontic treatment visit; may also be billed out as any combination of D0330, D0340, D0350, and D0470.
- D8680 Orthodontic retention (removal of appliances, construction/placement).
- D8690 Orthodontic treatment (alternative billing to a contract fee).
- D8999 Unspecified orthodontic procedure, by report.
- D9310 Consultation – diagnostic services other than requesting provider.
This page was last modified on: 9/18/2017 12:26:50 PM