Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE
Table D - Schedule of Dental Procedures
Universal Citation: 89 IL Admin Code ยง D
Current through Register Vol. 48, No. 38, September 20, 2024
Effective January 1, 2018. Additional dental services may be approved based on medical necessity.
a) Diagnostic Services
1) Clinical Oral
Evaluations
A) Oral Exams
i) For ages 0-20 - Limited to two every 12
months per patient in an office setting and one per school year in a school
setting; and
ii) For ages 21 and
over - Limited to one every 12 months per patient
B) Limited Exam
C) Comprehensive Exam
2) X-rays
b) Preventive Services
1) Prophylaxis
A) For ages 0-20 - Limited to one every 6
months per patient in an office setting and one per school year in a school
setting; and
B) For ages 21 and
over - Limited to one every 12 months per patient
2) Topical Application of Fluoride (ages
0-20) - limited to one every 6 months per patient in an office setting and one
per school year in a school setting
3) Fluoride Varnish (ages 0-2) - limited to
three per 12 months per patient ages 0-2 years in an office setting
4) Sealants (ages 0-20) - limited to one per
two years per tooth regardless of place of service
5) Space Maintenance (ages 0-20) - limited to
one per lifetime per quadrant
c) Restorative Services
1) Amalgams
2) Resins
3) Crowns
4) Other Restorative Services
d) Endodontic Services
1) Pulpotomy - limited to ages 0-20
2) Endodontic Therapy (ages 21 and over;
limited to anterior teeth only)
3)
Apexification/Recalcification Procedures limited to ages 0-20
4) Apicoectomy/Periradicular Services limited
to ages 0-20
e) Periodontal Services
1) Surgical
Services
2) Non-Surgical
Periodontal Services
3) Other
Periodontal Services
f) Removable Prosthodontic Services
1) Complete
Denture
2) Partial Denture -
limited to ages 0-20
3) Repairs to
Complete Denture
4) Repairs to
Partial Denture
5) Denture Reline
Procedures
g) Maxillofacial Prosthetics
h) Prosthodontics Fixed limited to ages 0-20
1)
Fixed Partial Denture Pontics
2)
Fixed Partial Denture Retainers - Crowns
3) Other Fixed Partial Denture
Services
i) Oral and Maxillofacial Services
1)
Extractions
2) Surgical
Extractions
3) Other Surgical
Procedures
4)
Alveoloplasty
5) Surgical Excision
of Intra-osseous Lesions
6)
Surgical Incision
7) Treatment of
Fractures - Simple
8) Treatment of
Fractures - Compound
9) Reduction
of Dislocation and Management of Other Temporomandibular Joint
Dysfunctions
10) Other Repair
Procedures
j) Orthodontic Services limited to ages 0-20
1) Comprehensive
Orthodontic
2) Other Orthodontic
Services
k) Adjunctive General Services
1) Unclassified
Treatment
2) Anesthesia
3) Professional Consultation
4) Drugs
Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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