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Your
Benefit Fund dental program has a Pre-determination of Benefits requirement for
any plan of treatment and/or service submitted by a non-participating provider
that is equal to or exceeding $1,000. In addition, all periodontal and
orthodontia services must be pre-determined, regardless of who is providing the
service. You are responsible for advising your dentist of this requirement. The
pre-determination must be accompanied by a properly mounted set of diagnostic
quality x-ray films and any other pertinent documentation that may be deemed
necessary to adequately make a review for available benefits. The failure to
submit for the required pre-authorization will result in a forfeiture of
benefits.
Predetermination
allowances are payable only after the following conditions are applied.
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The claimant must be eligible for benefits when the described services
are incurred. In the case of termination
from the Fund, an expense is incurred when the service is performed,
except in cases of:
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Dentures,
or fixed bridgework - when the final impression is taken;
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Crown
work - when preparation of the tooth is begun;
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Root
canal therapy - when root canal treatment is completed.
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So
long as there has not been a change in the plan of benefits prior to
performance of the service that would thus vary the allowance indicated.
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So
long as the total benefit payments for all treatment of a patient in any
benefit period does not exceed plan maximums.
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The
allowances may be reduced by Coordination of Benefits, if applicable, to
each patient.
The
Benefit Fund shall have the right to request that a member or his/her dependent
undergo an oral examination to verify treatment recommended in a
Predetermination review, or following treatment to determine the extent of
services rendered. This requirement applies where clarifying information can
only be obtained in this way. Failure to comply will result in forfeiture of
benefits.
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The
Fund reserves the right to examine dental patients to assure that in all cases
proper care, procedures and costs have been assigned. It periodically reviews
prescribed courses of treatment in individual cases to determine whether the
Alternate Benefit Provision should be authorized and payments limited
accordingly
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If
an alternate benefit can be provided, giving consideration to professionally
acceptable alternate procedures, services, or courses of treatment, the Fund
will determine the amount of benefits payable, that would accomplish the desired
results. (The attending dentist and the patient may proceed with the original
treatment plan regardless of the Fund's benefit determination.)
For
example, a payment for a crown will not be allowed if an acceptable professional
result can be obtained by placing a filling in the tooth. A payment will be made
as if a filling was placed in the tooth that received the crown. Upon
presentation of documentation satisfactory to the Fund that the tooth can only
be restored by a crown, payment will be made
for a crown.
The
Fund retains the right to limit the number of payments to be made for dental
services in circumstances that, in the Fund's sole judgment, require such
limitation.
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The
Fund has made arrangements with many
local dentists who have agreed to accept
the fees listed in this booklet as payment in full. Should you decide to use one
of the participating dentists, no charges will be made for any of the eligible
dental services listed and payments will be made directly from the Fund to your
dentist. Frequency limits and general exclusions remain the same no matter which
dentist (participating or otherwise) you might choose.
Participating
dentists may charge you for services not listed in the Schedule of Dental
Benefits, but such services should be infrequently encountered, if at
all.
Please
refer to the list of participating dentists for those offices accepting the Fund
plan. Dentists who specialize in orthodontia, periodontia, endodontia or oral
surgery are listed separately from general dentists. This list will be revised
from time to time by the Fund so check with the Fund office to verify the status
of the provider you have chosen.
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Schedule
of Benefits
The
maximum amount payable for each individual for the listed dental services will
be $2,250 in any calendar year, exclusive of orthodontia or periodontia services,
which have separate maximums of $2,000 in any calendar year for periodontia,
$1,995 in a lifetime for adolescent and adult orthodontia.
Retirees
have an all-inclusive annual maximum of $750 per family, $500 per individual.
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Covered
dental expenses will not include, and no payments will be made for, expenses
incurred for the performance of any dental service not provided for in this
schedule. In special instances, the Fund Trustees may agree to accept certain
expenses as covered dental expenses. To submit the expenses to the Fund for
consideration, the dental service should be identified in terms of the American
Dental Association Uniform Code of Dental Procedures and Nomenclature (codes for
covered services listed in following schedule) and by narrative description. If
expenses incurred for a dental service not expressly provided for in this
Schedule are accepted by the Fund, the covered dental expense for that dental
service will be determined while remaining consistent with those
listed
in this Schedule and will be conclusive and binding. In any event, expenses
incurred for instruction for plaque control, oral hygiene instruction, bite
registrations, or for dental services, that do not have uniform professional
endorsement, will not be accepted by the Benefit Fund as covered dental
expenses.
A
temporary dental service will be considered an integral part of the final dental
service rather than a separate service. The Fund will not absorb or be
responsible for any fees or charges that are owed by a member that exceed the
benefits herein. The Fund reserves the
right to request and receive any additional information it deems necessary to
properly adjudicate the claim. |