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Healthfirst’s Medical, Dental, and Oral Health Coverage Reimbursement Policy
Effective date
Jul 1, 2025
Identified
Jun 20, 2026
Summary
Healthfirst's Medical, Dental and Oral Health Coverage Reimbursement policy (PO-RE-169v2) covers dental services under the medical benefit when they are medically necessary and directly related to or integral to a covered medical service, such as reconstruction of the dental ridge after surgical removal of a tumor or stabilization of teeth in connection with a jaw fracture. Claims for these services must include a valid ICD-10-CM diagnosis code and a valid CDT procedure code, and the KX modifier is required effective July 1, 2025. The 4/20/2026 revision replaced CPT/HCPCS procedure code requirements with CDT procedure code requirements, and routine dental services remain excluded unless covered under the member's plan.
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What to do
Action · 6 steps
01Already effective 2025-07-01: Billing team: include the KX modifier on dental services billed under the medical benefit, as it is required.
02Billing team: submit appropriate CDT procedure codes that accurately reflect the dental service provided, since claims submitted without a valid CDT code may be denied.
03Billing team: include a valid ICD-10-CM diagnosis code that supports medical necessity and reflects the medical condition requiring dental intervention, and keep documentation of that medical condition and of the diagnosis codes supporting a qualifying condition.
04Billing team: submit claims electronically on 837P or 837I, since electronic submission is strongly encouraged.
05Billing team: when another insurer is primary, include the explanation of benefits with the claim and include appropriate MSP indicators when applicable.
06Dental services that are not directly related to or integral to a covered medical condition or procedure will be denied under the medical benefit.
Codes mentioned
D0120D0140D0150D0160D0170D0171D0180D0190D0191D0210D0220D0230D0240D0250D0251D0270D0272D0273D0274D0277D0310D0330D0340D0350D0364D0365D0366D0367D0368D0380D0381D0382D0383D0384D0391D0414D0415D0416D0431D0460D0470D0472D0473D0474D0475D0476D0477D0478D0479D0480D0481D0482D0483D0484D0485D0486D0604D0605D0701D0702D0703D0705D0706D0707D0708D0709D0801D0802D0803D1110D4341D4342D4346D4355D7111D7140D7210D7220D7230D7240D7241D7250D7251D7261D7270D7272D7280D7282D7284D7285D7286D7287D7288D7290D7291D7292D7293D7294D7298D7299D7300D7310D7311D7320D7321D7340D7350D7410D7411D7412D7413D7414D7415D7440D7441D7450D7451D7460D7461D7465D7471D7472D7473D7485D7510D7511D7520D7521D7530D7540D7953D7961D7963D7970D7971D7972D7997
Original notice
Healthfirst’s Medical, Dental, and Oral Health Coverage Reimbursement Policy
hfproviders.org · Always check the source before changing claims.
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