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Provider Manual

Dental/Oral Surgery Benefits

Last Updated on May 21, 2020


Family Health Center has two levels of providers for dental services: 
  • Level I = FHC Dental Center Providers 
  •  Level II = Any other FHC contracted dentist (including Marshfield Clinic)
Level I Provider:
Benefits for dental care when received from a Level I provider - please contact Family Health Center Customer Service at 1-800-942-5420.

Level II Provider:
Benefits for dental care when received from a Level II provider:
  • Services for minors (17 years of age or younger) – all of the below are covered with no frequency limitations:
    •  Oral examination
    •  Full mouth x-rays
    •  Pulp treatment
    •  Pulp cap
    •  Amalgam fillings
    •  Resin restoration
    •  Sealants
    •  Stainless steel crowns
    •  Cement base
    •  Root canals
    •  Space maintainer (band loops)
    •  Space maintainers (lingual arches)
    •  Re-cement bands
  •  Services for adults (over age 17):
    •  Preventive cleanings & fluoride treatment is covered at 100%. Frequency is based on patient’s age:
      •  Age 20 & younger: once per 6 months (must have 5 months between visits)
      •  Age 21 & older: Once per 12 months (must have 11 months between visits)
    •  Removal of impacted/erupted teeth (includes exams & x-rays related to extractions) – covered if done in office
  •  Not covered services with a Level II provider – services will be denied to the patient.
    •   Treatment of chewing accidents
    •  Fillings or crowns for patients >17 years
    •  Services performed in an ambulatory surgery, outpatient or inpatient hospital setting.
    •  Alveoloplasty
    •  Dentures
    • Dental implant services
    •  Periodontia surgery
    •  Root canal
    •  TMJ dysfunction treatment 
    •  Orthodontic braces
Oral Surgery
Oral surgery services performed in an ambulatory surgery or outpatient hospital setting are not covered. Services will be denied to the patient.