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Limitations & Exclusions
The following
exclusions are common to most dental benefit plans (in other
words, the following is not covered):
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Any dental services which were not rendered or approved by a
participating dentist except in cases of out-of-area dental
emergency.
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A service not furnished by a Dentist, unless the service is
performed by a licensed dental hygienist under the
supervision of a dentist or for an x-ray ordered by a
dentist.
Under the dental contract, benefits can
only be provided for services rendered by licensed
practitioners.
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Treatment of a disease, defect, or injury covered by a major
medical plan, Workmen's Compensation Law, occupational
disease law, or similar legislation.
This excludes services that may be
covered by other plans or federal/state benefit programs. In
such cases, private dental coverage is not available.
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Any dental procedures which are undertaken primarily for
cosmetic reasons, or dental care to treat accidental
injuries, congenital or developmental malformations.
Dental benefit plans are only intended
to provide coverage for the treatment of dental disease and
other tooth related problems. Services rendered for cosmetic
purposes are not covered.
-
Restorations, crowns or fixed prosthetics when acceptable
results can be achieved with alternative methods or
materials. In cases where the selection of a more expensive
treatment plan is decided upon, the Plan will allow for the
least costly alternative and the patient is responsible for
all additional fees charged by the dentist.
Because dental conditions can often be
treated in many ways, coverage must be limited to the least
costly method that would produce a satisfactory result.
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Services which were started prior to the person becoming
covered under this plan.
Benefits only apply to treatment
rendered while a person is covered under the plan. Services
provided before (or after) a period of eligibility can not
be covered.
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Implants, precision attachments or other personalized
restorations or specialized techniques.
Most plans have such services excluded
because they may have limited success and because they may
be subject to alternate treatment plans.
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Broken Appointments - If specified by Plan Dentist for
appointments not canceled 24 hours in advance, there is a
$30.00 charge.
This only applies to patients enrolled
in Managed Care Plans that operate through participating
dentists. By calling to cancel a scheduled visit, the
dentist may be able to appoint another patient in need of
care. If the time is forfeited without proper notice, the
dentist may charge for the lost time.
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Replacement of any existing crown, bridge or denture, which
can be made serviceable according to common dental
standards.
This clarifies that the plan will
provide benefits only for services that medically necessary.
New dental prosthetics are only provided if existing
appliances are not functional and cannot be repaired.
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Procedures, appliances or restorations whose main purpose is
to: change vertical dimension; diagnose or treat conditions
or dysfunction of the temporomandibular joint; stabilize
periodontally involved teeth, or restore occlusion.
The plan covers crowns, bridges and
dentures only for restorative purposes or to replace missing
teeth. These services are not covered because of periodontal
disease, malocclusion or other reasons.
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Treatment of unmanageable children or otherwise unruly
patients. An attempt will be made to treat all patients.
However, if a patient is untreatable by virtue of
apprehension or any other reason, and is referred to another
office for treatment, the responsibility for payment lies
with either the patient or with the parents of the patient.
Enrollees in the managed care plan must
be treated by participating dentists in order to be covered.
If patients receive treatment from a non-participating
dentist for any reason, neither the company nor its
providers are responsible for such treatment. If patients
need to be treated by private dentists, they should select a
standard type of plan that allows benefits at any location.
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Services not listed in the Schedule of Benefits are not
covered.
The following
limitations are common to most dental benefit plans:
° Exams, recall x-rays,
prophylaxes, scaling and fluoride treatment - Once every 6 mos.
° Full mouth and panoramic x-rays - Once every 36 mos.
° Crowns, bridges, dentures & periodontal surgery - Once every
60 mos.
° Orthodontic treatment of Class II/Class III malocclusions -
One 24 month case.
° These limitations are based on standard dental practice
guidelines and are acknowledged by most insurance companies,
dental benefit organizations and dental associations.
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