Dental Documents / Guides
2026 Dental Clinical Review Criteria
- D0003 - Restorations Buildup and Determination of Non-Restorable Tooth
- D0004 - Prefabricated Crowns
- D0006 - Single Tooth Indirect Restorations
- D0007 - Pulp Therapy Root Canal Treatment and Referrals
- D0008 - Oral Surgery Procedures and Referrals
- D0009 - Periodontal Services and Referrals
- D0011 - Sedation and Behavior Management
- D0017 - Occlusal Guards Coverage and Bleaching Exclusions
- D0018 - Cone Beam Computed Tomography
- D0019 - Space Maintainers
Current Matrices
Archived Matrices
- 2024 Dental Matrix – Over 21
- 2024 Dental Matrix – Under 21
- 2023 Dental Matrix – Over 21
- 2023 Dental Matrix – Under 21
- 2022 Dental Matrix – Over 21
- 2022 Dental Matrix – Under 21
- 2021 Dental Matrix – Over 21
- 2021 Dental Matrix – Under 21
- 2020 Dental Matrix – Over 21
- 2020 Dental Matrix – Under 21
Dental Prior Authorizations
Requests for dental services that require prior authorization can be submitted through our secure provider portal, by email to HCHdentaldeptHCA@azblue.com, or by mail to:
Blue Cross Blue Shield of Arizona Health Choice
Attn: HC Dental Prior Authorization
8220 N. 23rd Ave.
Phoenix, AZ 85021