Dental Claim Form

Participating Providers

Who is Eligible

Member and their eligible dependents as defined by the Fund.

What is the Benefit

Members and their dependents are eligible for reimbursement for dental expenses in accordance with the Fund’s established Schedule of Dental Benefits.

Active Level members, Active COBRA or “Self-Pay” Enhanced Retire Plan members are covered with maximums, per eligible member or dependent of:

Unlimited Maximum for General Dentistry

Unlimited Maximum for Periodontal Treatment

2 Implants Covered Per Year

$1,995 Lifetime for Orthodontics, Adolescent and Adults with a $1,000 co-pay for in-network providers. (Adult and Adolescent Orthodontia Update – June 2016)

Benefit Description for Active SPERP & Cobra Members

“No-Cost” Basic Retiree Members

and their dependents are limited to an Dental maximum annually of:

$750 per family, $500 per individual for all dental services.

Dental Plan is Administered by a Third-Party Administrator for “No-Cost” Basic Retirees

A third-party administrator is a firm that is hired by the Fund to process and pay claims.  In 2021, Healthplex was hired by the Fund to streamline the Fund’s Dental claims, increase our In-Network Provider List and save money. Healthplex , Inc. is not our insurance company. The Benefit Fund remains financially responsible for your covered benefits.

Healthplex administers the dental plan adopted by the Fund’s Board of Trustees. As our third-party administrator, Healthplex reviews all Fund dental claims to insure payments are made according to the guidelines set by the SCME Benefit Fund.

Making Claim for an In-Network Dental Provider:

Making a claim with an In-Network Dental provider will be handled between the participating dentist and Healthplex.  The member or their eligible dependent simply needs to sign the claim form at the dental office.

Making a Dental Claim for Out-of Network Dentists:

Request a claim form from your worksite (payroll representative), dentist’s office or print them directly from our website. All sections must be completed, including your original signature and the current date placed where indicated when you are utilizing the services of a non-participating provider. The dentist’s signature and tax identification number must be contained on all claim forms, regardless of their status with the Fund.

Predetermination Request

If the procedure or series of treatments is a covered procedure, clinically necessary and is expected to be over $1,000, you must have your dentist file for a predetermination BEFORE the work is done. Payment for such treatment, without this determination will be subject to a fine of $250.

Please return Predeterminations and Out-of-Network claim forms, signed and dated to:

PO Box 211672, Eagan, MN 55121

Please note: Incomplete claim forms will be returned to you for more information, which may cause a delay in your benefit payment.