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 Cigna.
Covered Dental Expense Covered Dental Expense means that portion of a Dentist’s charge that is payable for a service delivered to a covered person provided: the service is ordered or prescribed by a Dentist; is essential for the necessary care of teeth; the service is within the scope of coverage limitations; the deductible amount in The Schedule has been met; the maximum benefit in The Schedule has not been exceeded; the charge does not exceed the amount allowed under the Alternate Benefit Provision; for Class I, II or III the service is started and completed while coverage is in effect, except for services described in the “Benefits Extension” section. Alternate Benefit Provision If more than one covered service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, necessary and appropriate treatment. If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, Cigna recommends 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 x- rays and other diagnostic materials as requested by Cigna's dental consultant. If there is a change in the treatment plan, a revised plan should be submitted. Cigna will determine covered dental expenses for the proposed treatment plan. If there is no Predetermination of Benefits, Cigna will determine covered dental expenses when it receives 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. Covered Services The following section lists covered dental services. Cigna may agree to cover expenses for a service not listed. To be
HC-DEN1
04-10
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Dental PPO – Participating and Non- Participating Providers Plan payment for a covered 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 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.
HC-DEN171
07-14
V1
Class I Services – Diagnostic and Preventive Clinical oral examination – Only 2 per person per calendar year. Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive Dental Services are performed. (Any x-ray taken in connection with such treatment is a separate Dental Service.) X-rays – Complete series or Panoramic (Panorex) – Only one per person, including panoramic film, in any 36 consecutive months. Bitewing x-rays – Only 2 charges per person per calendar year. Prophylaxis (Cleaning), including Periodontal maintenance procedures (following active therapy) – Only 2 per person per calendar year.
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