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Provider Notice Issued 04/30/2021

Date:     April 30, 2021


To:       Dental Providers, Federally Qualified Health Centers (FQHCs), Encounter Rate Clinics (ERCs), and Rural Health Clinics (RHCs)


Re:      Dental Benefit Limitations Amended



This provider notice serves to inform dental providers that the Illinois Department of Healthcare and Family Services (HFS) will be temporarily amending benefit limitations for certain dental services. This change applies to claims billed for participants covered under fee-for-service as well as a HealthChoice Illinois managed care plan.

The following CDT dental code benefit changes are effective for children for dates of service starting May 1, 2021 until the COVID-19 public health emergency no longer exists.

CDT Code


Age Range/ Tooth #

Temporary Benefit Limitation


Periodic Oral Examination



One of (D0120) per 6 Month(s) per patient. Participants are also eligible for one periodic oral evaluation (D0120) performed in a school setting per school year (08/01/XXXX – 07/31/XXXX).  Completion of a mandated school exam form is considered part of the oral examination.


Prophylaxis – Child



One of (D1120, D4355) per 6 months in an office/mobile setting in addition to one per 6 months in school setting. Removal of plaque, calculus and stains from the tooth surfaces, intended to control local irrational factors.


Topical Application of Fluoride Varnish



One of (D1206, D1208) per 6 months in an office in addition to one per 6 months in a school setting.



Topical Application of Fluoride (excluding prophylaxis)


One of (D1206, D1208) per 6 months in an office in addition to one per 6 months in a school setting.



D1351 – Sealant – Per Tooth



Teeth 2, 3, 14, 15, 18, 19, 30, 31

One per 2 years per tooth regardless of place of service. Occlusal surfaces only. Teeth must be caries free. Sealant will not be covered when placed over restorations.


Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for fee-for-service claims, or to the individual HealthChoice Illinois managed care plan.


Kelly Cunningham, Administrator
Division of Medical Programs



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JB Pritzker, Governor • Theresa Eagleson, Director