The following section lists Covered Dental Services. We may agree to cover expenses for a service not listed. To be considered the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description and then submitted to Us.
Covered Dental Expenses Dental services described in this section are Covered Dental Expenses when such services are: • Medically Necessary and/or Dentally Necessary (refer to the section entitled Definitions); • Provided by or under the direction of a Dentist or other appropriate provider as specifically described; • Covered after Your Deductible, if any, has been met; • Eligible for reimbursement because the maximum benefit in The Schedule has not been exceeded; • The charge does not exceed the amount allowed under the Alternate Benefit Provision; and • Not excluded as described in the section entitled General Limitations and Expenses Not Covered. Alternate Benefit Provision If more than one Covered Dental Service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, Medically Necessary and/or Dentally Necessary, and appropriate treatment. If the Covered Person requests or accepts a more costly Covered Dental Service, the Covered Person is responsible for expenses that exceed the amount covered for the least costly service. Therefore, We recommend Predetermination of Benefits before major treatment begins. Predetermination of Benefits Predetermination of Benefits is a voluntary review of a Dentist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required. The treatment plan should include supporting pre-operative radiographic images and other diagnostic materials as requested by Our dental consultant. If there is a change in the treatment plan, a revised plan should be submitted. We will determine Covered Dental Expenses for the proposed treatment plan. If there is no Predetermination of Benefits, We will determine Covered Dental Expenses when We receive a claim. Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200. Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.
HCDFB-COV19
06-21
Payment Option If You or any one of Your Dependents, while insured for these benefits, incurs Covered Dental Expenses, We will pay an amount determined as follows: Dental PPO - Participating and Non-Participating Provider Payment Plan payment for a Covered Dental Service delivered by a Participating Provider is the Contracted Fee for that procedure, times the benefit percentage that applies to the class of service, as specified in The Schedule. The Covered Person is responsible for the balance of the Contracted Fee. Plan payment for a Covered Dental Service delivered by a Non-Participating Provider is the Maximum Reimbursable Charge for that procedure times the benefit percentage that applies to the class of service, as specified in The Schedule. The Covered Person is responsible for the balance of the Non- Participating Provider’s actual charge.
HCDFB-DEN133
06-21
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