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 03/02/2016
Member Name:
TORREY, MATTHEW A
Patient Name:
TORREY, MATTHEW A
Group ID:
00512404
Patient Date of Birth:
08/26/1976
Group Name:
EQUIX, INC
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
TORREY, MATTHEW A
Relationship
Prev
Basic
Perio
Major
Ortho
Member
12/02/2015
12/02/2015
12/02/2015
12/02/2015
12/02/2015
TMJ
Endo
Oral Srg
12/02/2015
12/02/2015
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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03/02/2016
Guardian Anytime
Coverage Information
Coverage Information
Preventive
DentalGuard
Preferred Dentist
Deductible
Waived
DentalGuard Plus and Non
Contracted Dentist
Deductible
Waived
100%
Yes
100%
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.
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 60 CONSECUTIVE MONTH PERIOD.
Other Preventive Services
SPACE MAINTAINERS, RECEMENTATION OF SPACE MAINTAINERS
AND HARMFUL HABIT APPLIANCES ARE CONSIDERED BASIC
CATEGORY SERVICES.
Basic
Anesthesia
80%
No
80%
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 AND SURGICAL EXTRACTIONS ARE CONSIDERED
MAJOR CATEGORY SERVICES.
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
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.
50%
No
50%
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No
03/02/2016
Guardian Anytime
Crowns/Inlays/Onlays/Post &
Cores/Buildups
SINGLE CROWNS ARE CONSIDERED A MAJOR SERVICE SUBJECT TO
REVIEW. PLEASE SUBMIT PRE-PROCEDURE RADIOGRAPHIC IMAGES.
REPLACEMENT POST & CORES ARE COVERED IF THE EXISTING POST
& CORE IS AT LEAST 10 YEARS OLD AND CANNOT BE REPAIRED.
REPLACEMENT CROWNS, INLAYS AND ONLAYS ARE COVERED IF THE
EXISTING APPLIANCE IS AT LEAST 10 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 10 YEARS OLD AND
CANNOT BE REPAIRED.
Implants
SURGICAL PLACEMENT OF IMPLANTS IS NOT COVERED. THE
PROSTHETIC APPLIANCE PLACED OVER THE IMPLANT WILL BE
CONSIDERED IF THE TOOTH WAS EXTRACTED WHILE INSURED WITH
THIS GUARDIAN PLAN AND SUBJECT TO ALL OTHER PLAN
PROVISIONS.
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
$50
$50
$150
$150
$1,500
$1,500
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
0
Maximum Rollover Amount
0
Rollover Amount if all Benefits Paid In-Network
0
Maximum Rollover Account Maximum
0
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
$2,000
19
Orthodontics Age Limit
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