What is included in the benefit?

Beginning January 1, 2024, the below services will be covered under this enhanced benefit. Use the accompanying procedure codes when submitting a claim. 

Providers must include remarks regarding the special health care need benefit on applicable claims to indicate the treatment was provided for a patient with special health care needs.

  • Additional visits to the dentist’s office
    This may include or be in addition to consultations that can be helpful prior to the first treatment to help patients learn what to expect and what is needed for a successful dental appointment. Additional exam benefits will be allowed for this purpose. (Procedure codes D0120, D0145, D0150, D0160 and D0180)
  • Up to four total dental cleanings in a benefit year
    (Procedure codes D1110, D1120, D4910, D4346 and D4355)
  • Treatment delivery modifications
    Any accommodations necessary for dental staff to provide oral health care for patients with sensory sensitivities, behavioral challenges, severe anxiety or other barriers to treatment. (Procedure code D9997)
  • Any anesthesia needs
    The use of anesthesia necessary to provide dental 
    care (Procedure codes D9222, D9223, D9239, D9243)

Benefit Verification

Before rendering services, please check the member’s procedure eligibility in the Dental Office Toolkit® to verify coverage. There is no age limit on these benefits.

If the member’s record has already been updated to allow for additional services under this benefit, there will be a message in the Dental Office Toolkit® confirming this. 

If there is not already a message in Dental Office Toolkit®, you should include code D9997 on the initial claim submission for this patient. After this first claim processes, the member’s procedure eligibility will update accordingly and you will no longer need to include D9997 on future claims for that member.

Training Opportunity

Center for Persons with Disabilities Presentation Series

With the goal of helping to improve access to dental care for individuals with disabilities, Penn Dental Medicine has established a FREE new continuing education series through the support of the Delta Dental Foundation.

The series, Center for Persons with Disabilities Presentation Series, is aimed at building awareness of the barriers to equitable oral health for individuals with disabilities, and developing competency to provide oral health care to this vulnerable population.

Access Course