Download Summary of Benefits - Dental HMO Smile Basic

Summary of Benefits - Dental HMO SmileSM Basic
D0120
D0140
D0145
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0270
D0272
D0273
D0274
D0330
D0431
D0460
D0470
D9310
D1110
D1120
D1203
D1206
D1330
D1351
D1352
D1510
D1515
D1520
D1525
D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
Office visit
Office visit
Diagnostic (exams and x-rays)
Periodic oral evaluation
Limited oral evaluation - problem focused
Oral evaluation for a patient under three years of age
Comprehensive oral evaluation
Detailed and extensive oral evaluation - problem focused
Re-evaluation - limited, problem focused (not post-operative visit)
Comprehensive periodontal evaluation
Intraoral radiographs - complete series (including bitewings) (once every 36 months)
Intraoral periapical radiograph - first film
Intraoral periapical radiograph - each additional film
Intraoral occlusal radiograph
Bitewing radiograph - single film
Bitewing radiograph - two films
Bitewings - three films
Bitewing radiograph - four films
Panoramic film (once every 36 months)
Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including
premalignant and malignant lesions, not to include cytology or biopsy procedures
Pulp vitality tests
Diagnostic casts
Specialist - consultation (as necessary)
Preventive (cleanings and fluoride)
Prophylaxis (adult) every 6 months
Prophylaxis (child) every 6 months
Topical application of fluoride - child
Topical fluoride varnish (covered through age 17)
Oral hygiene instruction
Sealant per tooth
Preventive resin restoration in a moderate to high caries risk patient - permanent tooth
Restorative (crown)
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable - unilateral
Space maintainer - removable - bilateral
Recementation of space maintainer
Removal of fixed space maintainer
Amalgam - one surface, primary or permanent
Amalgam - two surfaces, primary or permanent
Amalgam - three surfaces, primary or permanent
Amalgam - four or more surfaces, primary or permanent
Resin based composite - one surface, anterior
Resin based composite - two surfaces, anterior
Resin based composite - three surfaces, anterior
Resin based composite - four or more surfaces or involving incisal angle, anterior
Resin based composite crown, anterior
Resin based composite - one surface, posterior
DS-1
Member
Copayment
You pay nothing
$4
$6
$6
$7
$13
$6
$8
$11
$3
$2
$4
$2
$4
$5
$5
$10
$26
$5
$36
You pay nothing
$8
$6
$3
$4
$5
$5
$5
$110
$150
$136
$170
$28
$27
$46
$58
$70
$84
$55
$67
$82
$102
$150
$60 per tooth
DHMO06SG2 (1-13) An independent member of the Blue Shield Association
ADA Service / Benefit
Code
Summary of Benefits - Dental HMO SmileSM Basic
ADA Service / Benefit
Code
Member
Copayment
D2392
D2393
D2394
D2542
D2543
D2544
D2642
D2643
D2644
D2662
D2663
D2664
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2910
D2915
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2957
D2980
$78
$97
$116
$415
$433
$450
$430
$447
$463
$398
$412
$425
$369
$450
$419
$438
$480 each crown1
$467 each crown1
$428 each crown1
$448 each crown1
$460 each crown1
$435 each crown1
$445 each crown1
$350 each crown1
$463 each crown1
$425 each crown1
$446 each crown1
$36
$38
$36
$92
$110
$118
$120
$126
$38
$94
$24 per tooth
$144
$100
$116
$62
$97
D4210
D4211
D4240
D4241
D4260
Resin based composite - two surfaces, posterior
Resin based composite - three surfaces, posterior
Resin based composite - four or more surfaces, posterior
Onlay - metallic - two surfaces
Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three or more surfaces
Onlay - porcelain/ceramic - four or more surfaces
Onlay - resin-based composite - two surfaces
Onlay - resin-based composite - three surfaces
Onlay - resin-based composite - four or more surfaces
Crown - resin-based composite (indirect)
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominantly base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Recement inlay, onlay or partial coverage restoration
Recement cast or prefabricated post and core
Recement crown
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown
Prefabricated stainless steel crown with resin window - primary tooth
Prefabricated esthetic coated stainless steel crown - primary tooth
Protective restoration
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Post and core in addition to crown, indirectly fabricated
Each additional indirectly fabricated post, same tooth
Prefabricated post and core in addition to crown
Each additional prefabricated post - same tooth
Crown repair, by report
Periodontics (gum disease)
Gingivectomy/gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant
Gingivectomy/gingivoplasty one to three contiguous teeth or tooth bounded spaces - per
quadrant
Gingival flap procedure including root planing four or more teeth - per quadrant
Gingival flap procedure including root planing one to three teeth - per quadrant
Osseous surgery (including flap entry and closures) - four or more contiguous teeth or
DS-2
$263 per quadrant
$103
$313
$262
$446 per quadrant
Summary of Benefits - Dental HMO SmileSM Basic
ADA Service / Benefit
Code
D4261
D4263
D4264
D4266
D4267
D4270
D4271
D4273
D4341
D4342
D4355
D4381
D4910
D9951
D9952
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5225
D5226
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
Member
Copayment
tooth bounded spaces - per quadrant
Osseous surgery (including flap entry and closures) - one to three contiguous teeth or
tooth bounded spaces - per quadrant
Bone replacement graft - first site in quadrant
Bone replacement graft - each additional site in quadrant
Guided tissue regeneration - resorbable barrier - per site
Guided tissue regeneration - nonresorbable barrier - per site (includes membrane
removal)
Pedicle soft tissue graft procedure
Free soft tissue graft procedure (including donor site surgery)
Subepithelial connective tissue graft procedure - per tooth
Periodontal scaling and root planing - four or more teeth per quadrant
Periodontal scaling and root planing - one to three teeth per quadrant
Full mouth debridement before comprehensive treatment
Localized delivery of antimicrobial agents via a controlled release vehicle into diseased
crevicular tissue, per tooth, by report
Periodontal maintenance
Occlusal adjustment - limited
Occlusal adjustment - complete
Prosthetics removable (dentures)
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
Maxillary partial denture - resin base (including any conventional clasps, rests and
teeth)
Mandibular partial denture - resin base (including any conventional clasps, rests and
teeth)
Maxillary partial denture - cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth)
Mandibular partial denture - cast metal framework with resin denture bases (including
any conventional clasps, rests and teeth)
Maxillary partial denture - flexible base (including any clasps, rests and teeth)
Mandibular partial denture - flexible base (including any clasps, rests and teeth)
Removable unilateral partial denture - one piece cast metal (including clasps and teeth)
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Denture repair - complete denture, broken base
Denture repair - missing or broken teeth - complete denture - each tooth
Denture repair - acrylic saddle or base
Denture repair - cast framework
Denture repair - repair or replace clasp
Denture repair - broken tooth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Replace all teeth and acrylic on cast framework - maxillary
Replace all teeth and acrylic on cast framework - mandibular
Denture rebase - complete maxillary
Denture rebase - complete mandibular
DS-3
$368
$288
$213
$357
$413
$350
$374
$450
$84 per quadrant
$58
$62
$40
$46
$60 entire mouth
$213 entire mouth
$695 per denture
$695 per denture
$750 per denture
$750 per denture
$513 per denture1
$523 per denture1
$736 per denture1
$738 per denture1
$639 per denture1
$643 per denture1
$413 per denture1
$30
$30
$30
$30
$70
$62
$70
$100
$90
$62
$76
$92
$235
$235
$195
$195
Summary of Benefits - Dental HMO SmileSM Basic
ADA Service / Benefit
Code
Member
Copayment
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5850
D5851
$190
$190
$126 per denture
$126 per denture
$122 per denture
$124 per denture
$159 per denture
$160 per denture
$157 per denture
$157 per denture
$68 per denture unit
$69 per denture unit
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6545
D6548
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6710
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
Denture rebase - partial maxillary
Denture rebase - partial mandibular
Reline complete maxillary denture (chairside)2
Reline complete mandibular denture (chairside)2
Reline maxillary partial denture (chairside)2
Reline mandibular partial denture (chairside)2
Reline complete maxillary denture (laboratory)2
Reline complete mandibular denture (laboratory)2
Reline maxillary partial denture (laboratory)2
Reline mandibular partial denture (laboratory)2
Tissue conditioning - maxillary
Tissue conditioning - mandibular
Bridge abutments or pontics
Pontic - indirect resin based composite
Pontic - cast high noble metal
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic - cast titanium metal
Pontic - porcelain fused to high noble metal
Pontic - porcelain fused to predominantly base metal
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic
Pontic - resin with high noble metal
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Retainer - cast metal for resin bonded fixed prosthesis
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three or more surfaces
Onlay - cast high noble metal - two surfaces
Onlay - cast high noble metal - three or more surfaces
Onlay - cast predominantly base metal - two surfaces
Onlay - cast predominantly base metal - three or more surfaces
Onlay - cast noble metal- two surfaces
Onlay - cast noble metal - three or more surfaces
Bridge retainer - crown - indirect resin based composite
Bridge retainer - crown - resin with high noble metal
Bridge retainer - crown - resin with predominantly base metal
Bridge retainer - crown - resin with noble metal
Bridge retainer - crown - porcelain/ceramic
Bridge retainer - crown - porcelain fused to high noble metal
Bridge retainer - crown - porcelain fused to predominantly base metal
Bridge retainer - crown - porcelain fused to noble metal (anterior and premolar teeth
only)
Bridge retainer - crown - ¾ cast high noble metal
Bridge retainer - crown - ¾ cast predominantly base metal
Bridge retainer - crown - ¾ cast noble metal
Bridge retainer - crown - ¾ porcelain/ceramic (anterior and premolar teeth only)
Bridge retainer - crown - full cast high noble metal
Bridge retainer - crown - full cast predominantly base metal
Bridge retainer - crown - full cast noble metal
DS-4
$4401
$4801
$4561
$4691
$4751
$4921
$4671
$4751
$4961
$4771
$4601
$4681
$3311
$4161
$4501
$4901
$4631
$4951
$4441
$4791
$4521
$4881
$4431
$4501
$4261
$4381
$4801
$4671
$4281
$4481
$4581
$4321
$4451
$4711
$4601
$4251
$4431
Summary of Benefits - Dental HMO SmileSM Basic
ADA Service / Benefit
Code
Member
Copayment
D6930
D6970
D6972
D6973
D6975
D6976
D6977
D6980
$56
$1851
$145
$119
$296
$121
$801
$130 + lab
D3110
D3120
D3220
D3221
D3310
D3320
D3330
D3331
D3332
D3346
D3347
D3348
D3410
D3421
D3425
D3426
D3430
D3450
D3920
D3950
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7285
D7286
D7287
D7288
D7310
D7311
D7320
D7321
Recement fixed partial denture
Cast post and core in addition to fixed partial denture retainer, indirectly fabricated
Prefabricated post with core buildup in addition to fixed denture retainer
Core build up for retainer, including any pins
Coping - metal
Each additional indirectly fabricated post - same tooth
Each additional prefabricated post - same tooth
Fixed partial denture repair, by report
Endodontics (root canals)
Pulp cap (direct) excluding final restoration
Pulp cap (indirect) excluding final restoration
Pulpotomy
Pulpal debridement - primary and permanent tooth
Root canal therapy - anterior tooth (excluding final restoration)
Root canal therapy - bicuspid tooth (excluding final restoration)
Root canal therapy - molar tooth (excluding final restoration)
Treatment of root canal obstruction; non-surgical access
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
Retreatment of previous root canal - anterior
Retreatment of previous root canal - bicuspid
Retreatment of previous root canal - molar
Apicoectomy / periradicular surgery - anterior
Apicoectomy / periradicular surgery - bicuspid (first root)
Apicoectomy / periradicular surgery - molar (first root)
Apicoectomy / periradicular surgery - molar (each additional root)
Retrograde filling - per root
Root amputation - per root
Hemisection (including any root removal; not including root canal therapy)
Canal preparation and fitting of preformed dowel or post
Oral Surgery
Extraction of coronal remnants - deciduous tooth
Extraction of erupted tooth or exposed root
Surgical removal of erupted tooth
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partial bony
Removal of impacted tooth - complete bony
Removal of impacted tooth - complete bony with unusual surgical complications
Surgical removal of residual tooth roots
Oroantral fistula closure
Biopsy of oral tissue - hard (bone, tooth)3
Biopsy of oral tissue - soft3
Exfoliative cytological sample collection
Brush biopsy - transepithelial sample collection
Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per
quadrant
Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces,
per quadrant
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces,
DS-5
$28
$28
$66
$66
$243
$286
$346
You pay nothing
$177
$350
$400
$475
$283 first root
$316 first root
$367 first root
$151 each
additional root
$113
$200
$195
You pay nothing
$46 per tooth
$56 per tooth
$118 per tooth
$135 per tooth
$171 per tooth
$210 per tooth
$247
$130
$350
$133
$106
$58
$63
$124 per quadrant
$130 1 to 3 teeth
$180 per quadrant
$180 1 to 3 teeth
Summary of Benefits - Dental HMO SmileSM Basic
ADA Service / Benefit
Code
D7471
D7472
D7473
D7510
D7511
D7550
D7960
D7963
D7970
D7971
D7972
D9110
D9210
D9211
D9212
D9215
D9220
D9221
D9241
D9242
D9430
D9440
D9910
D9120
D8090
D8070
D8080
D8210
D8220
D8670
D8680
D8691
D8660
D9940
D9942
Member
Copayment
per quadrant
Removal of lateral exostosis maxilla or mandible
Removal of torus palatinus
Removal of torus mandibularis
Incision & drainage of abscess - intraoral soft tissue
Incision & drainage of abscess - intraoral soft tissue - complicated (includes drainage of
multiple facial spaces)
Partial ostectomy /sequestrectomy for removal of non-vital bone
Frenectomy/Frenotomy - separate procedure
Frenuloplasty
Excision of hyperplastic tissue - per arch
Excision of pericoronal gingival
Surgical reduction of fibrous tuberosity
Adjunctive General Services
Palliative (emergency) treatment of dental pain - minor procedure4
Local anesthesia not in conjunction with outpatient surgical procedures
Regional block anesthesia
Trigeminal division block anesthesia
Local anesthesia in conjunction with outpatient surgical procedures
General anesthesia - first 30 minutes
General anesthesia - each additional 15 minutes
IV sedation - first 30 minutes
IV sedation - each additional 15 minutes
Office visit for observation (during regularly scheduled hours) - no other services
performed
Office visit - after regularly scheduled hours
Application of desensitizing medicament
Other
Failed Appointment (without 24-hour notice)
Fixed partial denture sectioning
Orthodontics5, 6, 7
Orthodontic treatment to correct malocclusion, limited to one continuous two-year
course of treatment.
Comprehensive orthodontic treatment of the adult dentition5
Child - transitional dentition through age 185
Comprehensive orthodontic treatment of the adolescent dentition5
Removable appliance therapy
Fixed appliance therapy
Periodic orthodontic treatment visit (as part of contract)
Retainers
Repair of orthodontic appliance
Orthodontic initial consultation
Occlusal guards by report
Repair and /or reline of occlusal guard
$263
$315
$300
$98
$139
$217
$188
$205
$213
$100
$301
$40 per visit
You pay nothing
You pay nothing
You pay nothing
You pay nothing
$164
$67
$163
$60
$24
$56
$20
$25 per visit
$79
$2,700
$2,300
$2,600
$360
$406
You pay nothing
$250 per retainer
$88
$250
$245
$80
1
For DHMO Open plans, endnote should be: Precious metals, if used are included in the Copayment charge.
2
Denture relines if done within six (6) months of the initial insertion of a denture are considered part of the original denture
service and are included in the denture Copayment; denture relines after six (6) months of the initial insertion of a denture
require the additional denture reline Copayment.
DS-6
Summary of Benefits - Dental HMO SmileSM Basic
3
Subscriber pays lab fees for biopsies and excisions.
4
5
6
For an emergency oral exam with palliative treatment, if treatment includes a listed procedure, then regular Copayment
applies.
Full case fee includes consultation, treatment plan, tooth movement, and retention. Orthodontist may charge Members
separately for records, limited to $250 per case.
In order to be covered, orthodontic treatment: must be received in one continuous course of treatment; must be received in
consecutive months; and must not exceed 24 consecutive months.
7
The orthodontic benefit is subject to all plan limitations.
DS-7
Copayment of the covered Benefit plus the difference
between the Dentist’s usual and customary fee for the
covered Service and the selected procedure. If no dental
Service appearing on the Summary of Benefits is related
to the procedure selected, the service is excluded as listed
in the General Exclusions section of the Evidence of
Coverage. In all instances, Benefits will be provided for
Dentally Necessary restoration of tooth structure.
INTRODUCTION
The above are the Dental Care Services (Benefits) covered
by the Plan. Services are listed with the American Dental
Association (ADA) CDT-2005 procedure code. You will
note many procedures are performed without charge to the
Member. Copayments are listed where applicable. These
covered Services must be necessary, and must be provided
by the Member’s Dental Center or other Plan Provider
when referred by the Member's Dental Center and
Authorized by a contracted Dental Plan Administrator.
Coverage for these Services is subject to all terms,
conditions, limitations and exclusions of the Dental
Services Contract, to any conditions or limitations set
forth in the benefit descriptions below, and to the General
Exclusions and Limitations set forth in the Evidence of
Coverage.
C. EMERGENCY CLAIMS
The Plan's liability for Emergency Services rendered
outside of the Service Area will be limited to $50 in
Palliative Treatment Services only.
If Emergency
Services outside of the Service Area were received and
expenses were incurred by the Member, the Member must
submit a complete claim with the Emergency Service
record (a copy of the Dentist’s bill) for payment to a
contracted Dental Plan Administrator, within 1 year after
the treatment date. Please send this information to:
RESPONSIBILITY FOR COPAYMENTS,
CHARGES FOR NON-COVERED SERVICES
AND EMERGENCY CLAIMS
Dental Plan Administrator
Dental Member Services
425 Market Street, 12th Floor
San Francisco, CA 94105
A. MEMBER RESPONSIBILITY
If the claim is not submitted within this period, the Plan
will not pay for those Emergency Services, unless the
claim was submitted as soon as reasonably possible as
determined by the Plan.
If the services are not
preauthorized, a contracted Dental Plan Administrator will
review the claim retrospectively. If a contracted Dental
Plan Administrator determines that the services were not
Emergency Services and would not otherwise have been
authorized by a contracted Dental Plan Administrator, and,
therefore, are not Covered Services under this Contract, it
will notify the Member of that determination. The
Member is responsible for the payment of such Dental
Care Services received.
A contracted Dental Plan
Administrator will notify the Member of its determination
within 30 days from receipt of the claim. If the Member
disagrees with a contracted Dental Plan Administrator’s
decision, he may submit a grievance using the procedures
outlined in the Member Services and Grievance Process
section of the Evidence of Coverage.
1. The Member shall be responsible to the Dental Center
and other Plan Providers for payment of the following
charges:
a. Any amounts listed under Copayments in the
preceding Summary;
b. Any charges for non-covered services.
2. All such Copayments and charges for non-covered
services are due and payable to the Dental Center or
Plan Providers immediately upon commencement of
extended treatments or upon the provision of services.
Termination of the Plan shall in no way affect or limit
any liability or obligation of the Member to the Dental
Center or other Plan Provider for any such
Copayments or charges owing.
B. ELECTIVE TREATMENT FOR
NON-COVERED SERVICES
When the Member and Dentist opt to select a complicated
or personalized procedure that is more expensive than the
Covered Benefit, the Member will be responsible for the
Please be sure to retain this document. It is not a contract
but is a part of your Evidence of Coverage.
DS‐8