Download View Benefits - Dental Eligibility

Guardian Anytime
View Benefits - Dental Eligibility
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#64246
Predetermination
When the expected cost of a proposed course of treatment is
$300 or more, we recommend that a predetermination be
submitted to the Claims Address.
Dental Eligibility as of 10/19/2016
Member Name:
BOYER, DANIEL
Patient Name:
BOYER, DANIEL
Group ID:
00518603
Patient Date of Birth:
01/11/1996
Group Name:
KELLER GROUP
Dependent Age Limit:
26
Student Age Limit:
26
Effective Dates of Coverage (by Service Category)
Below are the effective dates of coverage for eligible patients. Dates may differ between service categories.
Name
BOYER, DANIEL
Relationship
Prev
Basic
Perio
Major
Ortho
Member
08/01/2016
08/01/2016
08/01/2016
08/01/2016
08/01/2016
TMJ
Endo
Oral Srg
08/01/2016
08/01/2016
Cosmetic
Plan Information
Your network is the DENTALGUARD PREFERRED DENTAL. Search for a Provider.
Your benefit period is from January 1 to December 31.
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Coverage Information
Coverage Information
Preventive
DentalGuard
Deductible
Preferred Dentist
Waived
100%
DentalGuard Plus and
Non Contracted Dentist
Deductible
Waived
100%
Yes
Yes
Last Eligible Service
Cleaning/Prophylaxis
THE PLAN COVERS EITHER ONE REGULAR PROPHYLAXIS OR A
PERIODONTAL MAINTENANCE IN ANY 6 CONSECUTIVE MONTH
PERIOD.
Cleaning/Prophylaxis:
Date Not Found
Fluoride
FLUORIDE IS COVERED UP TO AGE 19 SUBJECT TO ALL OTHER
PLAN PROVISIONS.
FLUORIDE IS COVERED ONCE IN ANY 6 CONSECUTIVE MONTH
PERIOD.
Fluoride: Date Not Found
Oral Exams
EXAMS ARE COVERED ONCE IN ANY 6 CONSECUTIVE MONTH
PERIOD (EXAMS INCLUDE PROCEDURES D0120, D0145, D0150,
D0170, D0171, D0180 AND D9430 - PROCEDURE D0140 IS NOT
INCLUDED IN THE EXAM FREQUENCY).
Oral Exams: Date Not Found
Palliative/Emergency
Treatment
Sealants
SEALANTS ARE COVERED ON DEPENDENTS UNDER AGE 16.
SEALANTS ARE LIMITED TO ONCE PER TOOTH IN ANY 36
CONSECUTIVE MONTH PERIOD.
SEALANTS ARE COVERED ON PERMANENT UNRESTORED MOLAR
TEETH ONLY.
X-Rays
BITEWING RADIOGRAPHIC IMAGES ARE LIMITED TO EITHER A
MAXIMUM OF 4 FILMS OR A SET OF VERTICAL BITEWINGS, IN ONE
VISIT, IN ANY 12 CONSECUTIVE MONTH PERIOD.
FULL MOUTH SERIES OR PANORAMIC FILMS ARE COVERED ONCE
IN ANY 36 CONSECUTIVE MONTH PERIOD.
Other Preventive Services
PREVENTIVE SERVICES ARE EXEMPT FROM THE REGULAR ANNUAL
MAXIMUM.
Basic
Anesthesia
70%
No
70%
Bitewing: Date Not Found
Full Mouth/Panoramic: Date Not
Found
No
ANESTHESIA IS CONSIDERED WITH THREE OR MORE COVERED
SIMPLE EXTRACTIONS OR ANY COVERED SURGICAL PROCEDURE.
Consultation
Endodontics/Root Canals
Fillings (Amalgam/Silver,
Composite/White or Tooth
Colored)
COMPOSITE RESTORATIONS ARE COVERED WITH NO SURFACE
RESTRICTION.
POSTERIOR RESINS (WHITE FILLINGS ON BACK TEETH) ARE NOT
COVERED, AN ALTERNATE BENEFIT OF AN AMALGAM (SILVER
FILLING) RESTORATION WILL BE CONSIDERED.
REPLACEMENT OF EXISTING RESTORATIONS IS LIMITED TO ONCE
IN ANY 12 CONSECUTIVE MONTHS FOR PATIENTS UNDER AGE 19,
OR ONCE IN ANY 36 CONSECUTIVE MONTHS FOR PATIENTS AGE 19
AND OLDER.
Oral Surgery
ORAL SURGERY CLAIMS FROM OUT OF NETWORK PROVIDERS
SHOULD FIRST BE SUBMITTED TO THE INSURED'S MAJOR MEDICAL
CARRIER.
Periodontal
Maintenance/Periodontal
Cleaning
PERIODONTAL MAINTENANCE COVERED AS A BASIC SERVICE.
THE PLAN COVERS EITHER ONE REGULAR PROPHYLAXIS OR A
PERIODONTAL MAINTENANCE IN ANY 6 CONSECUTIVE MONTH
PERIOD.
Periodontal Maintenance: Date Not
Found
Periodontics
PERIODONTAL SCALING & ROOT PLANING IS LIMITED TO ONE
TREATMENT, PER QUADRANT, IN ANY 24 MONTH PERIOD WHEN
NEEDED DUE TO GINGIVAL MIGRATION AND BONE LOSS.
Periodontal Scaling & Root
Planning: Date Not Found
Prosthetic Repairs/Rebase &
Relines
Other Basic Services
Major
Crowns/Inlays/Onlays/Post &
Cores/Buildups
REPAIRS AND MAINTENANCE ARE CONSIDERED MAJOR CATEGORY
SERVICES. THIS INCLUDES CODES D2910-D2920, D2980-D2983,
D5410-D5422, D5510-D5520, D5610-D5671, D5710-D5761,
D5850-D5851, D6092-D6093, D6640, D6930, D6980 AND D9120.
LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A
CONTROLLED RELEASE VEHICLE (E.G. ARESTIN, ACTISITE) IS NOT
A COVERED BENEFIT.
ORAL CANCER SCREENING (E.G. VIZILITE, VELSCOPE) IS NOT A
COVERED BENEFIT.
OCCLUSAL/MOUTH/NIGHT GUARDS ARE CONSIDERED ONLY ONCE
PER LIFETIME WHEN PERFORMED WITHIN 6 MONTHS OF OSSEOUS
SURGERY.
70%
No
70%
No
SINGLE CROWNS ARE CONSIDERED A MAJOR SERVICE SUBJECT
TO REVIEW. PLEASE SUBMIT PRE-PROCEDURE RADIOGRAPHIC
IMAGES.
REPLACEMENT CROWNS, INLAYS AND ONLAYS ARE COVERED IF
THE EXISTING APPLIANCE IS AT LEAST 5 YEARS OLD AND CANNOT
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BE REPAIRED.
REPLACEMENT POST & CORES ARE COVERED IF THE EXISTING
POST & CORE IS AT LEAST 5 YEARS OLD AND CANNOT BE
REPAIRED.
Fixed Bridges & Removable
Full & Partial Dentures
REPLACEMENT PARTIALS, DENTURES AND BRIDGES ARE
COVERED IF THE EXISTING APPLIANCE IS AT LEAST 5 YEARS OLD
AND CANNOT BE REPAIRED.
Implants
IMPLANT PROCEDURES COVERED WITHOUT REVIEW, WHEN THERE
IS A LIABILITY.
Other Major Services
TEETH MUST BE EXTRACTED WHILE INSURED WITH THIS
GUARDIAN PLAN TO BE CONSIDERED FOR PROSTHETIC
COVERAGE.
TMJ
Cosmetic
Cosmetic Deductible
Cosmetic Max
Individual Deductible
Family Deductible
Individual Dental max
$225
$250
$450
$500
$2,500
$2,500
Multi-visit procedures are paid on the preparation date.
Accumulator and Deductible Summary
Accumulator and Deductible Summary
In-Network
Out-of-Network
Maximum Met to Date for Benefit Period
$0.00
$0.00
Orthodontic Benefit Met to date
$0.00
$0.00
Deductible Met to Date for Benefit Period
$0.00
$0.00
MaxRollover Summary
Threshold
$900
Maximum Rollover Amount
$450
Rollover Amount if all Benefits Paid In-Network
$700
Maximum Rollover Account Maximum
$1,500
Personal Maximum Rollover Account
0.0
This is a sample of the maximum rollover benefits under this plan. It is not an all inclusive list nor is it a guarantee of the amount of benefits payable. All
benefits are subject to the patient's eligibility as defined by the plan on the date services are rendered.
Orthodontic
Orthodontic Coverage
50%
Orthodontic Deductible
Waived
Individual Lifetime Ortho Max
$1,000
19
Orthodontics Age Limit
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