N.M. Admin. Code § 13.10.6.11

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.6.11 - MINIMUM BENEFITS

All plans shall include at least the following basic dental services which shall be covered by the prepaid charges set forth in the evidence of coverage. If other dental services will be available to eligible members on a voluntary basis, they must be listed in the plan. Dental services not included in the plan shall be shown as exclusions.

A.Emergency services: Emergency dental services are those necessary to control bleeding, relieve pain, and eliminate acute infection.

B.Diagnostic services: Diagnostic dental services are those services necessary to identify dental abnormalities. They shall include but need not be limited to radiographs and clinical examination.

C.Preventive services: Preventive dental services shall include but need not be limited to oral prophylaxis, the application of topical fluorides when applicable, and a viable maintenance care recall system accompanied by evidence that this recall system is fully implemented.

D.Therapeutic services: Therapeutic services shall include:

(1) pulp therapy for permanent and primary teeth exclusive of root canal therapy,

(2) restoration of carious (decayed) permanent and primary teeth with materials other than cast restorations,

(3) routine tooth extractions.

E.Out of area care: In the event a member requires emergency dental services as defined in 13 NMAC 10.6.11.1 [now Subsection A of 13.10.6.11 NMAC] while located outside the geographic area served by the plan and the member pays for such services, reimbursement shall become the responsibility of the dental service provider from which the patient has elected to receive care under the contract.

N.M. Admin. Code § 13.10.6.11

11/20/79; Recompiled 11/30/01