Dental

Preventive dental visits for eligible members aged 18-20 years old

Mercy Care Dental Benefits Matrix

The health and well-being of our members is important. This is a reminder that preventive dental services specified in the AHCCCS Medical Policy Manual, Chapter 400 under Exhibit 430-1A - Dental Periodicity Schedule are covered benefits and Mercy Care allows:

  • Diagnostic services including comprehensive and periodic examinations.
  • Two oral examinations and two oral prophylaxis and fluoride treatments per member per year (i.e., one every six months plus 1 day apart).
  • Radiology services which are screening in nature for diagnosis of dental abnormalities and/or pathology, including panoramic or full-mouth x-rays, supplemental bitewing x-rays, and occlusal or periapical films as needed.
  • Oral prophylaxis performed by a dentist or dental hygienist which includes self-care oral hygiene instructions to member, if able, or to the parent/legal guardian.
  • Application of topical fluorides. (Use of a prophylaxis paste containing fluoride and fluoride mouth rinses do not meet the AHCCCS standard for fluoride treatment.)

Mercy Care also wants to remind you of multiple therapeutic and emergency dental services covered. Please keep in mind these services may need prior authorization. These services include but are not limited to:

  • Periodontal procedures, scaling/root planning, curettage, gingivectomy, and osseous surgery.
  • Precious or cast semi-precious crowns may be used on functional permanent endodontically treated teeth, except on third molars, for members 18 through 20 years of age. 
  • If the tooth has not been endodontically treated, stainless steel crowns may be placed on posterior teeth. Composite or prefabricated stainless steel crowns with resin windows may be used for anterior teeth.
  • Endodontic services include pulp therapy, except on third molars( unless the third molar is functioning in place of a missing molar)
  • Restoration of carious teeth with accepted dental materials.
  • Removable dental prosthetics, including complete dentures and removable partial dentures.
  • Orthodontic services and orthognathic surgery are covered only when the services are medically necessary to treat a handicapping malocclusion such as; congenital craniofacial or dentofacial malformations. Orthodontic services are not covered for cosmetic purposes.
  • Treatment for pain, infection, swelling, and/or injury.
  • Extraction of symptomatic, infected, and non-restorable primary and permanent teeth.
  • General anesthesia, conscious sedation, or anxiolysis (minimum sedation where the patient responds to verbal commands) when local anesthesia is contraindicated or when patient management requires it.

We are here to Help

You can contact the EPSDT Program staff at
Performance Improvement Department
Main Line: 602-659-9216
Fax: 959-282-1338
Email: performanceimprovement@mercycareaz.org

For clinical information or questions about members without dental coverage:

Lisa McLeod, RDH, MSc
Oral Health Liaison Program Coordinator
Medical Management Department
E-mail: McleodL@MercyCareAZ.org
Phone:   602-414-7385 

Training and educational information about oral and educational information integration can be found at SAMHSA-HRSA Center for Integrated Health Solutions.

Click to review the Mercy Care RBHA Dental Matrix

Thank you for making the health of our members a priority.