Dental Services Form

Dental Services 2025-2026 Clinical Practice Guidelines Applicable product: State of Illinois Model Contract Policy: Blue Cross and Blue Shield of Illinois promotes the use of the practice guidelines for dental services. Purpose: This guideline is designed to assist clinicians by providing a framework for evaluation and treatment of patients and is not intended to either replace a clinician’s judgment or establish a protocol for all patients with a particular condition. Regulatory requirements and references: State of Illinois Model Contract: 5.21.3.2; 5.22.3; Attachment XI (Quality Assurance) 1.1.1.1; 1.1.9; 1.1.9.13; Attachment XII: Utilization Review/Peer Review 1.1.2.3.2; Attachment XXI: Required Minimum Standards of Care 3. Covered Services Guideline: This guideline is based upon recommendations from the following resources: • American Dental Association • American Academy of Pediatric Dentistry • U.S. Food and Drug Administration Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Shield Association 255230.0725