Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Dental degree wikipedia , lookup
Dental hygienist wikipedia , lookup
Special needs dentistry wikipedia , lookup
Focal infection theory wikipedia , lookup
Remineralisation of teeth wikipedia , lookup
Tooth whitening wikipedia , lookup
Scaling and root planing wikipedia , lookup
Periodontal disease wikipedia , lookup
Endodontic therapy wikipedia , lookup
Delta Dental® Individual DeltaCare USA Pediatric Basic Plan Dental plan administered and underwritten by Delta Dental Insurance Company Available together with select medical plans offered through Health First Health Plans & Insurance Delta Dental Individual Pediatric Basic Plan W ith DeltaCare USA, there are no claim forms to submit. Select a DeltaCare USA dentist Receive your welcome kit Schedule an appointment Receive dental care Pay only your copayment directly to dentist Thank you for considering DeltaCare® USA for your dental coverage. When it comes to dental benefits, making the right choice doesn’t have to be complicated. DeltaCare USA plans are easy to use, and offer a great combination of affordability and dentist choice. Learn how DeltaCare USA plans work, and how to keep you healthy. About DeltaCare USA When new enrollees initially subscribe, they receive a list of dental procedures that show their share of the cost for covered services when provided by their selected DeltaCare USA network dentist. This share of the costs is called a copayment. When enrollees visit their DeltaCare USA dentist, they are only responsible for the copayment for each procedure at the time of treatment; but they must visit their selected DeltaCare USA dentist in order to receive benefits. In addition to knowing procedure costs up front, DeltaCare USA plans also provide other advantages. The plans do not require enrollees to satisfy a deductible, so they can start saving on out-of-pocket costs immediately. And with no annual maximum limitations, enrollees can use their DeltaCare USA benefits all year long. Plan features • DeltaCare USA plans include a copayment schedule when you enroll, so they’ll know their share of the cost for covered services before visiting the dentist. • DeltaCare USA plans include no deductibles and no annual benefit maximums for covered services. Underwritten by Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023 Administered by Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023 Customer Service 800-471-8148 deltadentalins.com • Low copayments or no copayments for many services such as cleanings and exams help keep smiles healthy by encouraging regular checkups and cleanings. • No claim forms to fill out – patients just pay their DeltaCare USA dentist the copayment amount at the time of service. • Easy-to-use DeltaCare USA dental plans provide a great balance of network dentist choice and affordability. Delta Dental Insurance Company provides benefits as a Prepaid Limited Health Services Organization as described in Chapter 636 of the Florida Statutes. HLT-DCU-O-I-FL-C70 Dentists you can trust • A network of private practice dental facilities that have been carefully screened for quality care and best practices • A large choice of dentists and low network turnover so that patients can enjoy a long-term relationship with their network dentist • Easy access to specialty care – DeltaCare USA network dentists will coordinate care if enrollees require treatment from a specialist for services covered under the plan DeltaCare USA plans offer many advantages Select a DeltaCare USA plan for these great features: • Coverage that can provide peace of mind. Our plans include no restrictions on pre-existing conditions (except for work in progress), and out-of-area dental emergency coverage. • Online services that make getting information quick and easy. Wherever you are - work, home or on the go - you can access account information and view benefits and eligibility, find a dentist and print ID cards. And our online tools are a snap to use on a smart phone, so we’re there when you need us. • T he SmileWay® Wellness Program provides resources such as dental health information, newsletters, risk quizzes and MySmileKids to help keep smiles healthy. • It’s easy to change DeltaCare USA dentists. Enrollees may change their selected network dentist at deltadentalins.com or by notifying us by phone or in writing. Requests made by the 21st of the month will become effective the first of the following month. This benefit information is only a summary and not intended or designed to replace or serve as a plan Contract or Policy. Please consult the Evidence of Coverage or Plan Policy for a complete description of plan benefits, limitations and exclusions. In the event of any inconsistency between this document and the Evidence of Coverage or Plan Policy, the terms of the Evidence of Coverage or Plan Policy will prevail. Read your Policy carefully. This brochure provides a brief description of the important features of your Policy. This is not the insurance Policy and only the Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is therefore important that you read your policy carefully. If you are not satisfied with the Policy for any reason, you may return the Policy within 10 days after you receive it. Mail or deliver it to Delta Dental Insurance Company. Any premium paid will be refunded. The Policy will then be void from its start. deltadentalins.com E INDIVIDUAL #74655 (9/13) Delta Dental Individual DeltaCare® USA Pediatric Basic Plan Plan Highlights DeltaCare USA provides great dental benefits and predictable costs. The plan provides a full list of copayments1 so the cost for covered services is never a surprise. Copayments for some of the most common services are listed below. Sample of Covered Services2 Category Procedure Code and Description3 Copayment Amount1 Pediatric Enrollees (up to age 19) Diagnostic & Preventive Services (D & P) Basic Services D0999 - Office visit No cost D0120 - Periodic oral exam – established patient No cost D0150 - Comprehensive oral evaluation – new or established patient No cost D0210 - Complete series of x-rays No cost D0220 - Periapical x-ray of tooth's root No cost D0230 - Periapical x-ray of tooth’s root, each additional image No cost D0272 - Bitewing x-rays (2 images) No cost D0274 - Bitewing x-rays (4 images) No cost D0330 - Panoramic x-ray No cost D1110 - Prophylaxis (cleaning) – adult No cost D1120 - Prophylaxis (cleaning) – child No cost D1208 - Fluoride treatment No cost D1351 - Sealant – per tooth No cost D2140 - Amalgam (silver-colored) filling – 1 surface No cost D2150 - Amalgam (silver-colored) filling – 2 surfaces No cost D2160 - Amalgam (silver-colored) filling – 3 surfaces No cost D2330 - Resin (tooth-colored) filling, front tooth, 1 surface No cost D2331 - Resin (tooth-colored) filling, front tooth, 2 surfaces No cost D2332 - Resin (tooth-colored) filling, front tooth, 3 surfaces No cost D2391 - Resin (tooth-colored) filling, back tooth, 1 surface No cost D2392 - Resin (tooth-colored) filling, back tooth, 2 surfaces No cost D2393 - Resin (tooth-colored) filling, back tooth, 3 surfaces No cost Category Procedure Code and Description3 Copayment Amount1 Pediatric Enrollees (up to age 19) Endodontics Periodontics Oral Surgery Major Services Orthodontics D3310 - Root canal, front tooth No cost D3320 - Root canal, bicuspid tooth No cost D3330 - Root canal, molar tooth No cost D4260 - Periodontal surgery, per quadrant D4341 - Periodontal scaling and root planing – four or more teeth per quadrant D4910 - Periodontal maintenance No cost D7140 - Extraction (removal) of a fully exposed tooth D7210 - Surgical extraction or erupted (exposed) tooth D7240 - Extraction (removal) of fully impacted tooth, completely bony No cost D2750 - Crown, porcelain and precious metal No cost D2790 - Crown, precious metal No cost D5110 – Full upper denture No cost D6240 - Bridge pontic, porcelain and precious metal No cost D6750 - Bridge crown, porcelain and precious metal No cost D8080 - Pediatric services – Medically necessary only No cost No cost No cost No cost No cost 1 A copayment is the amount the enrollee pays for covered services at the time of treatment. 2 Benefits featured above represent the most frequently used services covered under your plan; other services are also covered. After enrollment, the DeltaCare USA plan will make available a complete list of covered services and copayments, along with any limitations and exclusions that apply. 3 Copayments and procedure descriptions referenced above are intended to clarify the delivery of benefits under the DeltaCare USA plan and are not to be interpreted as CDT-2014 descriptors or nomenclature, which are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. HL_DCU_FL_O_I_PED_BSC_HEALTH_FIRST Description of Benefits and Copayments Delta Dental Individual DeltaCare® USA The Benefits shown below are performed as needed and deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the plan. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of Benefits under the DeltaCare® USA plan and is not to be interpreted as CDT-2014 procedure codes, descriptors or nomenclature which is under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. OOPM applies only to Essential Health Benefits (EHB) for Pediatric Enrollee(s). OOPM means the maximum amount of money that a Pediatric Enrollee must pay for covered dental services. Payment for Premiums and payment for services that are Optional, that are upgraded treatment (such as precious or semi-precious metals and material upgrades) or that are not covered under the Policy will not count toward the OOPM. Payment for such services will continue to apply even after the OOPM is met. Delta Dental recommends that the Pediatric Enrollee or other party responsible keep a record of payment for Benefits. Please refer to the medical portion of your benefits booklet for more information on the OOPM. Code Description D0100–D0999 I. DIAGNOSTIC D0999 Unspecified diagnostic procedure, by report D0120 Periodic oral evaluation - established patient (14) D0140 Limited oral evaluation - problem focused Pediatric Enrollee Pays No cost No cost No cost Clarifications/Limitations Includes office visit, per visit (in addition to other services) Limited to 2 of (D0120, D0150, D0180) per 12 month period Limited to 1 of per dentist per 12 month period D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost D0150 Comprehensive oral evaluation - new or established patient No cost D0160 Detailed and extensive oral evaluation problem focused, by report Comprehensive periodontal evaluation new or established patient No cost No cost Limited to 2 of (D0120, D0150, D0180) per 12 month period; limited to 1 of (D0180) per 12 month period No cost Limited to 1 series every 36 months D0240 Intraoral - complete series of radiographic images Intraoral - periapical first radiographic image Intraoral - periapical each additional radiographic image Intraoral - occlusal radiographic image D0250 Extraoral - first radiographic image No cost D0260 Extraoral - each additional radiographic image No cost D0180 D0210 D0220 D0230 Limited to 2 of (D0120, D0150, D0180) per 12 month period; limited to 1 of (D0150) per 12 month period No cost No cost No cost V14 Code Description D0270 Bitewing - single radiographic image Pediatric Enrollee Pays No cost D0272 Bitewings - two radiographic images No cost D0273 Bitewings - three radiographic images No cost D0274 Bitewings - four radiographic images No cost D0277 No cost D0330 Vertical bitewings - 7 to 8 radiographic images Panoramic radiographic image D0425 Caries susceptibility tests No cost D0460 Pulp vitality tests No cost D0470 Diagnostic casts No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost Limited to age 3 to 18; limited to 1 per 36 month period when performed the same Contract Dentist or office. D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost Limited to age 3 to 18; limited to 1 per 36 month period when performed the same Contract Dentist or office. D0603 Caries risk assessment and documentation, with a finding of high risk No cost Limited to age 3 to 18; limited to 1 per 36 month period when performed the same Contract Dentist or office. D1000-D1999 II. PREVENTIVE D1110 Prophylaxis - adult No cost Cleaning; limited to 2 of (D1110, D1120) per 12 month period D1120 Prophylaxis - child No cost D1206 D1208 D1351 Topical application of fluoride varnish Topical application of fluoride Sealant - per tooth No cost No cost No cost Cleaning; limited to 2 of (D1110, D1120) per 12 month period Limited to 2 per 12 month period Limited to 2 per 12 month period Limited to permanent molars without restorations or decay; limited to 1 of (D1351, D1352) per tooth every 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth No cost D1510 D1515 Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral D1520 D1525 D1550 Space maintainer - removable - unilateral Space maintainer - removable - bilateral Re-cementation of space maintainer No cost Clarifications/Limitations Limited to 1 series every 6 months Limited to 1 every 36 months Limited to permanent molars without restorations or decay; limited to 1 of (D1351, D1352) per tooth every 36 months No cost $ No cost No cost No cost No cost D2000-D2999 III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - Replacement of crowns, inlays and onlays requires the existing restoration to be 60+ months old. D2140 Amalgam - one surface, primary or permanent No cost D2150 Amalgam - two surfaces, primary or permanent No cost D2160 Amalgam - three surfaces, primary or permanent No cost V14 Code Description D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior No cost D2331 Resin-based composite - two surfaces, anterior No cost D2332 Resin-based composite - three surfaces, anterior No cost D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) No cost D2391 Resin-based composite - one surface, posterior No cost D2392 Resin-based composite - two surfaces, posterior No cost D2393 Resin-based composite - three surfaces, posterior No cost D2394 Resin-based composite - four or more surfaces, posterior No cost D2510 D2520 Inlay - metallic - one surface Inlay - metallic - two surfaces No cost No cost D2530 D2542 D2543 D2544 D2740 D2750 Inlay - metallic - three or more surfaces Onlay - metallic - two surfaces Onlay - metallic - three surfaces Onlay - metallic - four or more surfaces Crown - porcelain/ceramic substrate Crown - porcelain fused to high noble metal No cost No cost No cost No cost No cost No cost D2751 Crown - porcelain fused to predominantly base metal No cost D2752 D2780 D2781 Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominantly base metal No cost No cost No cost D2782 D2783 Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic No cost No cost D2790 D2791 Crown - full cast high noble metal Crown - full cast predominantly base metal Crown - full cast noble metal Crown - titanium Recement inlay, onlay, or partial coverage restoration No cost No cost D2920 D2930 Recement crown Prefabricated stainless steel crown primary tooth No cost No cost D2931 Prefabricated stainless steel crown permanent tooth No cost D2792 D2794 D2910 Pediatric Enrollee Pays No cost Clarifications/Limitations No cost No cost No cost Limited to one per Enrollee, per tooth, per lifetime through age 14 Limited to one per Enrollee, per tooth, per lifetime through age 14 V14 Code Description Pediatric Enrollee Pays No cost D2950 Core buildup, including any pins when required D2951 Pin retention - per tooth, in addition to restoration No cost D2954 Prefabricated post and core in addition to crown No cost D2980 Crown repair necessitated by restorative material failure No cost D2981 Inlay repair necessitated by restorative material failure No cost D2982 Onlay repair necessitated by restorative material failure No cost D2983 Veneer repair necessitated by restorative material failure No cost D2990 Resin infiltration of incipient smooth surface lesions No cost Clarifications/Limitations Includes canal preparation D3000-D3999 IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration) No cost D3120 Pulp cap - indirect (excluding final restoration) No cost D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament No cost D3221 Pulpal debridement, primary and permanent teeth No cost D3222 Partial pulpotomy for apexogenesis permanent tooth with incomplete root development No cost D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) No cost D3240 Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) No cost D3310 Endodontic therapy, anterior tooth (excluding final restoration) No cost Root canal D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) No cost Root canal D3330 Endodontic therapy, molar (excluding final restoration) No cost Root canal D3331 Treatment of root canal obstruction; nonsurgical access No cost D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy - anterior No cost D3346 No cost V14 Code Description D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy - molar No cost D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) No cost D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) No cost D3353 Apexification/recalcification - final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) No cost D3355 D3356 Pulpal regeneration - initial visit Pulpal regeneration - interim medication replacement No cost No cost D3357 Pulpal regeneration - completion of treatment No cost D3410 D3421 D3425 Apicoectomy - anterior Apicoectomy - bicuspid (first root) Apicoectomy - molar (first root) No cost No cost No cost D3426 D3427 Apicoectomy (each additional root) Periradicular surgery without apicoectomy Retrograde filling - per root Root amputation - per root Hemisection (including any root removal), not including root canal therapy No cost No cost D3430 D3450 D3920 Pediatric Enrollee Pays No cost Clarifications/Limitations No cost No cost No cost D4000-D4999 V. PERIODONTICS - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant No cost D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant No cost D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth No cost D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant No cost D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant No cost D4249 Clinical crown lengthening - hard tissue No cost V14 Code Description Pediatric Enrollee Pays No cost Clarifications/Limitations D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant No cost D4268 D4270 D4273 Surgical revision procedure, per tooth Pedicle soft tissue graft procedure Subepithelial connective tissue graft procedures, per tooth No cost No cost No cost D4275 D4276 Soft tissue allograft Combined connective tissue and double pedicle graft, per tooth No cost No cost D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft No cost D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site No cost D4341 Periodontal scaling and root planing four or more teeth per quadrant No cost Limited to 4 quadrants during any 24 consecutive months D4342 Periodontal scaling and root planing one to three teeth per quadrant No cost Limited to 4 quadrants during any 24 consecutive months D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis No cost Limited to 1 of per Enrollee per lifetime D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth No cost For each of the first two teeth treated within a quadrant following root planing or periodontal maintenance D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth No cost For an additional tooth treated in the same quadrant following root planing or periodontal maintenance D4910 Periodontal maintenance No cost Limited to 4 treatments each 12 month period D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist or office where the denture was originally delivered. - Replacement of a denture or a partial denture requires the existing denture to be 60+ months old. D5110 D5120 D5130 D5140 D5211 Complete denture - maxillary Complete denture - mandibular Immediate denture - maxillary Immediate denture - mandibular Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) No cost No cost No cost No cost No cost V14 Code Description D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) No cost D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) No cost D5281 Removable unilateral partial denture one piece cast metal (including clasps and teeth) No cost D5410 Adjust complete denture - maxillary No cost D5411 D5421 D5422 D5510 D5520 Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular Repair broken complete denture base Replace missing or broken teeth complete denture (each tooth) No cost No cost No cost No cost No cost D5610 Repair resin denture base No cost D5620 D5630 D5640 D5650 D5660 D5670 Repair cast framework Repair or replace broken clasp Replace broken teeth - per tooth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth and acrylic on cast metal framework (maxillary) No cost No cost No cost No cost No cost No cost D5671 Replace all teeth and acrylic on cast metal framework (mandibular) No cost D5710 D5711 D5720 D5721 D5730 Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) No cost No cost No cost No cost No cost D5731 Reline complete mandibular denture (chairside) No cost D5740 Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) No cost D5750 Reline complete maxillary denture (laboratory) No cost D5751 Reline complete mandibular denture (laboratory) No cost D5741 Pediatric Enrollee Pays No cost Clarifications/Limitations No cost V14 Code Description Pediatric Enrollee Pays No cost D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) No cost D5850 D5851 Tissue conditioning, maxillary Tissue conditioning, mandibular No cost No cost Clarifications/Limitations D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered D6000-D6199 VIII. IMPLANT SERVICES - Includes adjustments, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the implant was originally delivered. - Replacement of a retainer, pontic, or stress breaker requires the existing bridge to be 60+ months old. - FPD, as referenced below, stands for fixed partial denture. D6010 Surgical placement of implant body: endosteal implant No cost D6053 Implant/abutment supported removable denture for completely edentulous arch No cost D6054 Implant/abutment supported removable denture for partially edentulous arch No cost D6055 Connecting bar – implant supported or abutment supported No cost D6056 Prefabricated abutment – includes modification and placement No cost D6057 Custom fabricated abutment – includes placement No cost D6058 Abutment supported porcelain/ceramic crown No cost D6059 Abutment supported porcelain fused to metal crown (high noble metal) No cost D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) No cost D6061 Abutment supported porcelain fused to metal crown (noble metal) No cost D6062 Abutment supported cast metal crown (high noble metal) No cost D6063 Abutment supported cast metal crown (predominantly base metal) No cost D6064 Abutment supported cast metal crown (noble metal) No cost D6065 Implant supported porcelain/ceramic crown No cost D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) No cost D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) No cost D6068 Abutment supported retainer for porcelain/ceramic FPD No cost D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble No cost V14 Code Description Pediatric Enrollee Pays Clarifications/Limitations metal) D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) No cost D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) No cost D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) No cost D6074 Abutment supported retainer for cast metal FPD (noble metal) No cost D6075 Implant supported retainer for ceramic FPD No cost D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) No cost D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) No cost D6078 Implant/abutment supported fixed denture for completely edentulous arch No cost D6079 Implant/abutment supported fixed denture for partially edentulous arch No cost D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments No cost D6090 Repair implant supported prosthesis, by report No cost D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment No cost D6094 D6095 D6100 D6194 Abutment supported crown - (titanium) Repair implant abutment, by report Implant removal, by report Abutment supported retainer crown for FPD (titanium) No cost No cost No cost No cost D6072 No cost D6200-D6999 IX. PROSTHODONTICS, fixed - Each retainer and each pontic constitutes a unit in a fixed partial denture (bridge). - Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 60+ months old. D6210 D6211 D6212 D6214 Pontic - cast high noble metal Pontic - cast predominantly base metal Pontic - cast noble metal Pontic - titanium No cost No cost No cost No cost V14 Code Description D6240 Pontic - porcelain fused to high noble metal D6241 Pontic - porcelain fused to predominantly base metal No cost D6242 D6245 D6545 Pontic - porcelain fused to noble metal Pontic - porcelain/ceramic Retainer - cast metal for resin bonded fixed prosthesis No cost No cost No cost D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis No cost D6601 Inlay - porcelain/ceramic, three or more surfaces No cost D6604 Inlay - cast predominantly base metal, two surfaces No cost D6605 Inlay - cast predominantly base metal, three or more surfaces No cost D6613 Onlay - cast predominantly base metal, three or more surfaces No cost D6740 Crown - porcelain/ceramic No cost D6750 Crown - porcelain fused to high noble metal No cost D6751 Crown - porcelain fused to predominantly base metal No cost D6752 D6780 D6781 Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominantly base metal No cost No cost No cost D6782 Crown - 3/4 cast noble metal No cost D6783 D6790 D6791 Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal Crown - full cast predominantly base metal Crown - full cast noble metal Crown - titanium Recement fixed partial denture Fixed partial denture repair necessitated by restorative material failure No cost No cost No cost D6792 D6794 D6930 D6980 Pediatric Enrollee Pays No cost Clarifications/Limitations No cost No cost No cost No cost D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth No cost D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) No cost D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth - soft tissue No cost D7220 No cost V14 Code Description D7230 Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony D7240 Pediatric Enrollee Pays No cost Clarifications/Limitations No cost D7241 Removal of impacted tooth - completely bony, with unusual surgical complications No cost D7250 Surgical removal of residual tooth roots (cutting procedure) No cost D7251 Coronectomy – intentional partial tooth removal No cost D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth No cost D7280 Surgical access of an unerupted tooth No cost D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant No cost D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant No cost D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant No cost D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant No cost D7471 Removal of lateral exostosis (maxilla or mandible) No cost D7510 Incision and drainage of abscess intraoral soft tissue No cost D7910 D7921 Suture of recent small wounds up to 5 cm Collection and application of autologous blood concentrate product No cost No cost D7971 Excision of pericoronal gingiva No cost V14 Code Description Pediatric Clarification/Limitations Enrollee Pays D8000-D8999 XI. ORTHODONTICS - Medically Necessary for Pediatric Enrollees ONLY - Orthodontic Services must meet medical necessity as determined by a dentist. Orthodontic treatment is a benefit only when medically necessary as evidenced by a severe handicapping malocclusion and when a prior authorization is obtained. Severe handicapping malocclusion is not a cosmetic condition. Teeth must be severely misaligned causing functional problems that compromise oral and/or general health. - Medically necessary Orthodontic Services are limited to Pediatric Enrollees who have been enrolled in the Policy for 24 consecutive months. Benefits are not provided for orthodontic treatment including all services related to orthodontic treatment (such as diagnostic and pre-treatment records) until the 24 month Waiting Period is satisfied. Prior coverage for Pediatric Enrollees under a Delta Dental exchange certified pediatric essential dental plan will be credited towards the Pediatric Waiting Period under this dental plan. In order for prior coverage to be credited, such prior coverage must occur immediately preceding the election of this plan. - Pediatric Enrollee must continue to be eligible, benefits for medically necessary orthodontics will be provided in periodic payments to the Contract Dentist. - Comprehensive orthodontic treatment procedures (D8080, D8090) include all appliances, adjustments, insertion, removal and post treatment stabilization (retention). No additional charge to the Enrollee is permitted except for services provided by an orthodontist other than the original treating dentist or dental office. - Refer to Schedule B for Limitations and Exclusions for Medically Necessary Orthodontics for additional information. D8080 Comprehensive orthodontic treatment of No cost the adolescent dentition D8090 Comprehensive orthodontic treatment of No cost the adult dentition D8660 Pre-orthodontic treatment visit No cost Included in comprehensive case fee; a D8670 Periodic orthodontic treatment visit (as No cost separate fee applies for services provided by part of contract) an orthodontist other than the original treating orthodontist or dental office Included in comprehensive case fee; a D8680 Orthodontic retention (removal of No cost separate fee applies for services provided by appliances, construction and placement an orthodontist other than the original of retainer(s)) treating orthodontist or dental office who was paid for banding Included in comprehensive case fee; a D8693 Rebonding or recementing of fixed No cost separate fee applies for services provided by retainers an orthodontist other than the original treating orthodontist or dental office D8694 Repair of fixed retainers, includes reattachment No cost D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of No cost dental pain - minor procedure D9220 Deep sedation/general anesthesia - first No cost 30 minutes Included in comprehensive case fee; a separate fee applies for services provided by an orthodontist other than the original treating orthodontist or dental office Covered only when given by a Contract Dentist for covered oral surgery D9221 Deep sedation/general anesthesia - each additional 15 minutes No cost Covered only when given by a Contract Dentist for covered oral surgery D9241 Intravenous conscious sedation/analgesia - first 30 minutes No cost Covered only when given by a Contract Dentist for covered oral surgery D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes No cost Covered only when given by a Contract Dentist for covered oral surgery; limited to 3 per day V14 Code Description D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit - after regularly scheduled hours D9440 Pediatric Enrollee Pays No cost Clarification/Limitations No cost D9610 Therapeutic parenteral drug, single administration No cost D9612 No cost D9940 Therapeutic parenteral drugs, two or more administrations, different medications Treatment of complications (postsurgical) - unusual circumstances, by report Occlusal guard, by report No cost Age 13 and up; limited to 1 per 12 month period D9941 D9974 Fabrication of athletic mouthguard Internal bleaching - per tooth No cost No cost Limited to 1 per 12 month period Limited to 1 per tooth per 36 month period D9999 Unspecified adjunctive procedure, by report No cost Includes failed appointment without 24 hour notice D9930 No cost Endnotes: Base metal is the benefit. If noble or high noble metal (precious) is used for a crown, bridge, indirectly fabricated post and core, inlay or onlay, the Enrollee will be charged the additional laboratory cost of the noble or high noble metal. If covered, an additional laboratory charge also applies to a titanium crown. Porcelain/ceramic crown, pontic and fixed bridge retainer on molars is considered a material upgrade with a maximum additional charge to the Enrollee of $150 per unit. For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75 per unit. When there are more than six crowns, retainers and/or pontics in the same treatment plan, an Enrollee may be charged an additional $125 per unit, beyond the 6th unit. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325 in addition to the listed Copayment. Refer to Schedule B for Limitations and Exclusions for additional information. If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized in writing by the plan. The Enrollee pays the Copayment specified for such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filed fees”. “Filed fees” mean the Contract Dentist’s fees on file with the plan. Questions regarding these fees should be directed to the Customer Service department at 800-471-9925. Optional is defined as any alternative procedure presented by the DeltaCare USA dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee and is subject to the limitations and exclusions of the plan. The applicable charge to the Enrollee is the difference between the DeltaCare USA dentist's usual and customary fee for the Optional procedure and the usual and customary fee for the covered procedure, plus any applicable Copayment for the covered procedure. V14 Limitations and Exclusions of Benefits for Pediatric Benefits Delta Dental Individual DeltaCare® USA Limitations and Exclusions of Benefits for Pediatric Enrollees (Under age 19) Benefits and Limitations for Diagnostic Services: 1. Two oral evaluations (D0120, D0150 and D0180) are covered in a 12 consecutive month period. 2. Only one (1) comprehensive evaluation (D0150, D0180) will be allowed in a 12 consecutive month period. 3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per Enrollee per dentist in a 12 consecutive month period. 4. Detailed and extensive oral evaluations (problem-focused) (D0160) are limited to once per Enrollee per dentist, per life of the contract. 5. Bitewing x-rays in conjunction with periodic examinations are limited to one (1) series of four (4) films in any six (6) consecutive month period. Isolated bitewing or periapical films are allowed on an emergency or episodic basis. 6. Full mouth x-rays in conjunction with periodic examinations are limited to once every thirty-six (36) consecutive months. 7. Panoramic x-rays are limited to once every thirty-six (36) consecutive months. Benefits and Limitations for Preventive Services: 1. Two routine prophylaxes (D1110, D1120) are covered in a 12 consecutive month period. 2. Two topical fluoride applications are covered in a 12 consecutive month period. 3. Sealants (D1351, D1352) are covered only on permanent molars. The teeth must be caries free with no restorations on the mesial, distal or occlusal surfaces. One sealant per tooth is once every thirty-six (36) consecutive months. Benefits and Limitations for Restorative Services: 1. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 24 months of the original restoration are included, and a separate fee is not chargeable to the Enrollee by a Contract Dentist. However, coverage may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy. 2. The covered restorations includes all related services including, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents. 3. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury. They are limited to one per Enrollee, per tooth, per lifetime. 4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials, including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer Service department at 800-471-9925 if you have questions regarding the additional fee or name brand services. 5. Onlays, permanent single crown restorations, and posts and cores for Enrollees 12 years of age or younger are excluded from coverage, unless specific rationale is provided indicating the reason for such treatment (e.g., fracture, endodontic therapy, etc.) and is approved by the plan. 6. Core buildups (D2950) can be considered for benefits only when there is insufficient retention for a crown. A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities in the preparation. 7. Replacement of crowns, onlays, buildups, and posts and cores is covered only if the existing crown, onlay, buildup, or post and core was inserted at least sixty (60) months prior to the replacement and satisfactory evidence is presented that the existing crown, onlay, buildup, or post and core is not and cannot be made serviceable. Satisfactory evidence must show that the existing crown, onlay, buildup, or PIScBhi-FL-dc-15 1 V14 post and core is not and cannot be made serviceable. The sixty (60) month service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month. 8. Onlays, crowns, and posts and cores are covered only when necessary due to decay or tooth fracture. However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, coverage is for that service. Crowns, inlays, onlays, buildups, or posts and cores, begun prior to the effective date of coverage or cemented after the cancellation date of coverage, are not eligible for coverage. 9. Recementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per 6 month period. Recementation provided within 12 months of placement by the same dentist is included at no additional cost to the Enrollee. Benefits and Limitations for Endodontic Services: 1. Pulpotomies are included when performed by the same dentist within a 45-day period prior to the completion of root canal therapy. 2. A pulpotomy is covered when performed as a final endodontic procedure and is covered generally on primary teeth only. Pulpotomies performed on permanent teeth are included to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth. 3. Pulpal therapy (resorbable filling) is limited to primary teeth only. It is a benefit for primary incisor teeth for Enrollees up to age six and for primary molars and cuspids to age 11 and is limited to once per tooth per lifetime. 4. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment. 5. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed. Benefits and Limitations for Periodontal Services: 1. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone replacement grafts and osseous surgery provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth are not covered. 2. Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival flap procedure are not covered. 3. Subepithelial connective tissue grafts and combined connective tissue and double pedicle grafts are covered at the level of free soft tissue grafts. 4. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved. Another site on the same tooth is included to the first site reported. Non-contiguous areas involving different teeth may be reported as additional sites. 5. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth. 6. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or intrabony defects. It is not covered when provided to obtain root coverage, or when provided in conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g., apicoectomy or hemisection. 7. One crown lengthening per tooth, per lifetime, is covered. 8. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal surgical procedures, in the same area of the mouth is not covered. 9. Up to four periodontal maintenance procedures and up to two routine prophylaxes may be covered within a 12 consecutive month period, but the total of periodontal maintenance and routine prophylaxes may not exceed four procedures in a 12 month period. 10. Periodontal maintenance is only covered when performed following active periodontal treatment. 11. An oral evaluation reported in addition to periodontal maintenance will be covered as a separate procedure subject to the policy and limitations applicable to oral evaluations. 12. Coverage for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and guided tissue regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater surgical procedure. 13. Full mouth debridement to enable comprehensive evaluation and diagnosis (code D4355) is covered once per lifetime. Benefits and Limitations for Oral Surgery Services: 2 V14 1. Charges for related services such as necessary wires and splints, adjustments, and follow up visits are included to the fee for reimplantation and/or stabilization. 2. Routine postoperative care such as suture removal is included to the fee for the surgery. 3. The removal of impacted teeth is covered based on the anatomical position as determined from a review of x-rays. If the degree of impaction is determined to be less than the reported degree, coverage will be based on the allowance for the lesser level. 4. Removal of impacted third molars in Enrollees under age 15 is not covered unless specific documentation is provided that substantiates the need for removal and is approved by the plan. Benefits and Limitations for Prosthodontic Services: 1. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to Effective Date of Coverage may not be eligible for coverage. 2. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however, the dentist who fabricated the dentures may be reimbursed for the dentures after insertion if another dentist, typically an oral surgeon, inserted the dentures. 3. Removable cast base partial dentures for Enrollees under 12 years of age are excluded from coverage unless specific rationale is provided indicating the necessity for that treatment and is approved by the plan. 4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials, including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer Service department at 800-471-9925 if you have questions regarding the additional fee or name brand services 5. Re-cementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per 6month period. Recementation provided within 12 months of placement by the same dentist is included at no additional cost to the Enrollee. Adjustments provided within six months of the insertion of an initial or replacement denture or implant are included at no additional cost to the Enrollee when made by the same dentist. 6. With the exception of a new immediate denture, relining or rebasing is covered at no additional cost to the Enrollee within six months of a denture’s initial delivery. 7. A reline/rebase is covered once in any 36 months. 8. Fixed partial dentures, buildups, and posts and cores for Enrollees under 16 years of age are not covered unless specific rationale is provided indicating the necessity for such treatment and is approved by the plan. 9. Coverage for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture. Specialized procedures performed in conjunction with an overdenture are not covered. 10. A fixed partial denture and removable partial denture are not covered benefits in the same arch. Coverage is for a removable partial denture to replace all missing teeth in the arch. 11. Precision attachments, personalization, precious metal bases, and other specialized techniques are not covered benefits. 12. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a three unit fixed partial denture. 13. Replacement of removable prostheses (D5110 through D5214) and fixed prostheses (D6210 through D6792) is covered only if the existing removable and/or fixed prostheses was inserted at least sixty (60) months prior to the replacement and satisfactory evidence is presented that the existing removable and/or fixed prostheses cannot be made serviceable. Satisfactory evidence must show that the existing removable prostheses and/or fixed prostheses cannot be made serviceable. The sixty (60) month service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month. 14. Replacement of dentures that have been lost, stolen, or misplaced is not a covered service. 15. Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after 3 V14 the cancellation date of coverage are not eligible for coverage. Policies, Limitations, and Exclusions for Orthodontic Services - Medically Necessary: 1. Services are limited to medically necessary orthodontics when provided by a Contract Dentist and when necessary and customary under generally accepted dental practice standards. Orthodontic treatment is a benefit of this plan only when medically necessary as evidenced by a severe handicapping malocclusion for Pediatric Enrollees and shall be prior authorized by the plan. 2. Orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26 points on the Handicapping Labio-Lingual Deviation (HLD) Index or one of the automatic qualifying conditions below exist. 3. The automatic qualifying conditions are: a. Cleft palate deformity. If the cleft palate is not visible on the diagnostic casts written documentation from a credentialed specialist shall be submitted, on their professional letterhead, with the prior authorization request, b. A deep impinging overbite in which the lower incisors are destroying the soft tissue of the palate, c. A crossbite of individual anterior teeth causing destruction of soft tissue, d. Severe traumatic deviation. 4. The following documentation must be submitted to the plan with the request for prior authorization of services by the Contract Dentist: • ADA 2006 or newer claim form with service code(s) requested; • Diagnostic study models (trimmed) with bite registration; or OrthoCad equivalent; • Cephalometric radiographic image or panoramic radiographic image; • HLD score sheet completed and signed by the Orthodontist; and • Treatment plan. 5. The allowances for comprehensive orthodontic treatment procedures (D8080, D8090) include all appliances, adjustments, insertion, removal and post treatment stabilization (retention). No additional charge to the Enrollee is permitted. 6. Comprehensive orthodontic treatment includes the replacement, repair and removal of brackets, bands and arch wires by the original treating orthodontist. 7. Orthodontic procedures are benefits for medically necessary handicapping malocclusion, cleft palate and facial growth management cases for Pediatric Enrollees and shall be prior authorized. 8. Only those cases with permanent dentition shall be considered for medically necessary handicapping malocclusion, unless the Enrollee is age 13 or older with primary teeth remaining. Cleft palate and craniofacial anomaly cases are a benefit for primary, mixed and permanent dentitions. Craniofacial anomalies are treated using facial growth management. 9. All necessary procedures that may affect orthodontic treatment shall be completed before orthodontic treatment is considered. 10. When specialized orthodontic appliances or procedures chosen for aesthetic considerations are provided, the plan will make an allowance for the cost of a standard orthodontic treatment. 11. Repair and replacement of an orthodontic appliance inserted under the Plan that has been damaged, lost, stolen, or misplaced is not a covered service. 12. Should an Enrollee’s coverage be canceled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or termination, except: If an Enrollee is receiving ongoing orthodontic treatment at the time of termination, the plan will continue to provide orthodontic Benefits for: 4 V14 a. For 60 days if the Enrollee is making monthly payments to the Contract Orthodontist; or b. Until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the Enrollee is making quarterly payments to the Contract Orthodontist. At the end of 60 days (or at the end of the Quarter), the Enrollee’s obligation shall be based on the Contract Orthodontist’s usual fee at the beginning of treatment. The Contract Orthodontist will prorate the amount over the number of months to completion of the treatment. The Enrollee will make payments based on an arrangement with the Contract Orthodontist. Benefits, Limitations and Exclusions for Medically Necessary Orthodontics by Procedure Code: Comprehensive Orthodontic Services Procedure D8080 Comprehensive orthodontic treatment of the adolescent dentition The allowances for comprehensive orthodontic treatment procedures include all appliances, adjustments, insertion, removal and post treatment stabilization (retention). No additional charge to the Enrollee is permitted. Procedure D8090 Comprehensive orthodontic treatment of the adult dentition The allowances for comprehensive orthodontic treatment procedures include all appliances, adjustments, insertion, removal and post treatment stabilization (retention). No additional charge to the Enrollee is permitted. Other Orthodontic Services Procedure D8660 Pre-orthodontic treatment visit Under the plan processing policies, this procedure is considered to be equivalent to procedure D0150, and is a benefit only for Enrollees with orthodontic coverage. Procedure D8670 Periodic orthodontic treatment visit (as part of contract) Periodic treatment visits are part of, and included in the case fee for comprehensive orthodontic treatment. Procedure D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 1. Under the plan processing policies, the removal of orthodontic appliances is considered part of, and included in the comprehensive case fees for, orthodontic treatment when performed by the same dentist or dental office. 2. When this service is provided by a dentist or dental office other than the original treating orthodontist, please submit a narrative report. Procedure D8690 Orthodontic treatment (alternative billing to a contract fee) 1. The plan considers this procedure to be included in the orthodontic case fee. A separate fee may not be charged to the Enrollee when submitted by the same dentist or dental office as the orthodontic treatment. A separate fee applies for services provided by an orthodontist other than the original treating orthodontist. This is limited to transfer of care and removal of appliances. Procedure D8693 Rebonding or recementing; and/or repair, as required, of fixed retainers 1. The plan considers this procedure to be included in the comprehensive case fee. A separate fee may not be charged to the Enrollee when submitted by the original treating dentist or dental office. 2. This procedure may be benefitted if performed by a dentist or dental office other than the original treating dentist or dental office. Fees for subsequent procedures attributable to lack of Enrollee compliance are the Enrollee’s financial responsibility. 5 V14 Procedure D8694 Repair of fixed retainers, includes reattachment 1. The plan considers this procedure to be included in the orthodontic case fee. A separate fee may not be charged to the Enrollee when submitted by the same dentist or dental office as the orthodontic treatment. This procedure may be benefitted if performed by a different dentist or dental office other than the original treating orthodontist/dental office. Fees for subsequent procedures attributable to lack of Enrollee compliance are the Enrollee’s financial responsibility. Benefits and Limitations for General Services: 1. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) and when rendered by a dentist or other professional licensed dentist and approved to provide anesthesia in the state where the service is rendered. 2. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when determined to be medically or dentally necessary for documented handicapped or uncontrollable Enrollees or justifiable medical or dental conditions. 3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which it was provided must be submitted. 4. Deep sedation/general anesthesia and intravenous conscious sedation submitted without a report will be denied as a non-covered benefit. 5. For palliative (emergency) treatment to be covered; it must involve a problem or symptom that occurred suddenly and unexpectedly that requires immediate attention. 6. In order for palliative (emergency) treatment to be covered, the dentist must provide treatment to alleviate the Enrollee’s problem. If the only service provided is to evaluate the Enrollee and refer to another dentist and/or prescribe medication, it would be considered a limited oral evaluation - problem focused. 7. Consultations are covered only when provided by a dentist other than the practitioner providing the treatment. 8. Consultations reported for a non-covered benefit, such as Temporomandibular Joint Dysfunction (TMJD), are not covered. 9. After hours visits are covered only when the dentist must return to the office after regularly scheduled hours to treat the Enrollee in an emergency situation. 10. Therapeutic drug injections are only covered in unusual circumstances, which must be documented by report. They are not benefits if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication. 11. Preparations that can be used at home, such as fluoride gels, special mouth rinses (including antimicrobials), etc., are not covered benefits. 12. Occlusal guards are covered by report for Enrollee 13 years of age or older when the purpose of the occlusal guard is the treatment of bruxism. Occlusal guards are limited to one per 12 consecutive month period. 13. Athletic mouth guards are limited to one per 12 consecutive month period. 14. Internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior teeth. 15. Internal bleaching of discolored teeth (D9974) is eligible once per tooth per thirty-six (36) month period. Non-Covered Services Except as specifically provided, the following services, supplies, or charges are not covered: 1. Any dental service or treatment not specifically listed as a covered service. 2. Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, the plan will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law. 3. Services or treatment provided by a member of the Enrollee’s immediate family. 4. Those services submitted by a dentist which are for the same services performed on the same date for the same Enrollee by another dentist. 5. Those which are experimental or investigative (deemed unproven). 6. Those which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit. This exclusion applies whether or not the member claims the benefits or compensation. 6 V14 7. Those which are later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law. 8. Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law. 9. Those for which the member would have no obligation to pay in the absence of this or any similar coverage. 10. Those received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group. 11. Those performed prior to the Enrollee’s effective coverage date. 12. Those incurred after the termination date of the member’s coverage unless otherwise indicated. 13. Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist. (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the Enrollee by a Contract Dentist unless the dentist notifies the Enrollee of his/her liability prior to treatment and the Enrollee chooses to receive the treatment. Contract Dentists should document such notification in their records.) 14. Those not meeting accepted standards of dental practice. 15. Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association. 16. Those performed by a dentist who is compensated by a facility for similar covered services performed for members. 17. Those resulting from the Enrollee’s failure to comply with professionally prescribed treatment. 18. Telephone consultations. 19. Any charges for failure to keep a scheduled appointment. 20. Duplicate and temporary devices, appliances, and services. 21. Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMJD). 22. Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth. 23. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is covered under a plan or policy of motor vehicle insurance, including a certified selfinsurance plan. 24. Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization. 25. Services or treatment provided as a result of intentionally self-inflicted injury or illness. 26. Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection. 27. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient). 28. Adjunctive dental services as defined by applicable federal regulations. 29. Charges for copies of Enrollees’ records, charts or x-rays, or any costs associated with forwarding/mailing copies of Enrollees’ records, charts or x-rays. 30. State or territorial taxes on dental services performed. Adjunctive Services 1. Adjunctive dental care is dental care that is: a. Medically necessary in the treatment of an otherwise covered medical (not dental) condition. b. An integral part of the treatment of such medical condition. c. Essential to the control of the primary medical condition. d. Required in preparation for or as the result of dental trauma, which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic). 2. The plan does not cover adjunctive dental care services. These are medical services that may be covered under a medical policy even when provided by a general dentist or oral surgeon. The following diagnoses or conditions may fall under this category: a. Treatment for relief of Myofascial Pain Dysfunction Syndrome (MFPS) or Temporomandibular Joint Dysfunction (TMJD). b. Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for, or as a result of, trauma to teeth and supporting structures caused by medically necessary treatment of an injury or disease. c. Procedures associated with preventive and restorative dental care when associated with radiation therapy to the head or neck unless otherwise covered as a routine preventive procedure 7 V14 under this plan. d. Treatment of total or complete ankyloglossia. e. Treatment of an extraoral abscess or intraoral abscess that extends beyond the dental alveolus, f. Treatment of cellulitis and osteitis, which is clearly exacerbating and directly affecting a medical condition currently under treatment. g. Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an accidental injury. h. Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues associated with traumatic injury (such as a gunshot wound) in addition to services related to treating neoplasms or iatrogenic dental trauma.) 8 V14