Clinical Policies
CP.DP.1 Comprehensive & Periodic Evaluations (PDF)
DP.MM.001 Secondary Services to Primary Non- Covered Services (PDF)
CP.DP.2 Problem-Focused & Limited Evaluations (PDF)
CP.DP.3 EPSDT (PDF)
CP.DP.4 Sealants (PDF)
CP.DP.5 Orthodontic Treatment (PDF)
CP.DP.6 Non-Surgical Periodontics (PDF)
CP.DP.7 Single Tooth Indirect Restorations (PDF)
CP.DP.9 IV Moderate Sedation, IV Deep Sedation, and General Anesthesia (PDF)
CP.DP.10 Behavior Guidance (Management) (PDF)
CP.DP.11 Extraction of Impacted Teeth (PDF)
CP.DP.12 New Techonology (PDF)
CP.DP.13 Clefts & Craniofacial Anomalies (PDF)
CP.DP.14 Tobacco Counseling (PDF)
CP.DP.15 Administration of Therapeutic Drugs (PDF)
CP.DP.16 Dental Restoration Definitions (PDF)
CP.DP.17 Prefabricated Crowns (PDF)
CP.DP.18 Prophylaxis (PDF)
CP.DP.19 Topical Fluoride Application (PDF)
CP.DP.20 Endodontic Treatment (PDF)
CP.DP.21 Inhalation of Nitrous Oxide-Oxygen (PDF)
CP.DP.22 Caries Arresting Medicament (PDF)
CP.DP.23 Surgical Extraction (PDF)
CP.DP.24 Removal of Residual Tooth Roots (PDF)
CP.DP.25 Removable Prosthodontics (PDF)
CP.DP.26 Incision and Drainage (PDF)
CP.DP.27 Gingivectomy & Gingival Flap Surgery (PDF)
CP.DP.28 Osseous Surgery (PDF)
CP.DP.30 Excision of Soft Tissue (PDF)
CP.DP.31 Excision of Bone Tissue (PDF)
CP.DP.32 Removal of Foreign Body (PDF)
CP.DP.33 Alveoloplasty (PDF)
CP.DP.34 Occlusal Guards (PDF)
CP.DP.35 Vestibuloplasty (PDF)
CP.DP.36 Removable & Fixed Appliance Therapy (PDF)
CP.DP.37 Indirect Fixed Prosthodontic Restorations (PDF)
CP.DP.38 Space Maintainers (PDF)
CP.DP.39 Core Buildups, Posts & Cores (PDF)
CP.DP.40 Full Mouth Debridement (PDF)
CP.DP.41 Frenectomy (Frenulectomy) (PDF)
CP.DP.42 Caries Preventive Medicament Application (PDF)
CP.DP.43 Required Patient Record Documentation (PDF)
CP.DP.44 Orthognathic Surgery (PDF)
CP.DP.45 Obstructive Sleep Apnea (PDF)