2008 PEBB Benefits: Assessment Based X-ray & Cleaning Benefits

Assess each PEBB member using the below criteria as a general guide. Determine how frequently services are needed and let the patient know ways they can reduce their disease risk. The PEBB plan benefits more than one cleaning per year if your assessment determines this is needed - for reasons other than the historical precedent of two cleanings per year.*

X-ray Frequency
	Benefit	Criteria
Base Benefit	14 or younger Bitewings once per calendar year Full mouth or panoramic every 5 years 15 or older Bitewings once every two calendar years Full mouth or panoramic every 5 years	N/A
High Benefit	Bitewings two per calendar year Full mouth or Panoramic every three years	Two or more basic restorations in the last 24 months Pertinent patient history (Progressive periodontal disease, growth abnormalities, unusual eruption sequences or spacing, enamel hypoplasia).

Prophylaxis and Periodontal Maintenance Frequency
	Benefit	Criteria
Base Benefit	One prophylaxis per calendar year	N/A
Medium Benefit	No more than two prophylaxis per calendar year	Patients with active periodontal disease Orthodontic patients Tobacco users Patients unable to attain good preventive home care
HighBenefit	No more than four prophylaxis per calendar year	Patients with more severe periodontal disease (5+ mm pocket depth in more than one quadrant) Patients with diabetes Pregnant women (3 per year) Problems from dry mouth not treatable with additional fluoride, other measures (This can be due to medications, radiation and/or disease process.)
High Perio Benefit	No more than four prophylaxis or periodontal maintenance services per calendar year (Total four in combination)	History of specific periodontal therapy – as indicated by codes listed D4240 D4263 D4268 D4276 D4241 D4264 D4273 D4341 D4260 D4266 D4274 D4342 D4261 D4267 D4275

* If your assessment determines only one cleaning per year is qualified, but the patient wants additional cleanings, we request you collect payment from the member for the additional cleanings and not bill ODS. If your system automatically bills the insurance, then please note the words patient request in the claim remark section on the 2nd cleaning.