Predetermination Of Dental Benefits
Your Benefit Fund dental program has a Pre-determination of Benefits requirement for any plan of treatment and/or service submitted by a 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.
- 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:
- Dentures, or fixed bridgework – when the final impression is taken;
- Crown work – when preparation of the tooth is begun;
- Root canal therapy – when root canal treatment is completed.
- 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.
- So long as the total benefit payments for all treatment of a patient in any benefit period does not exceed plan maximums.
- 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.
Periodic Review of Treatment
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
Alternate Benefit Provision
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.
Participating Dental Program
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. There are some exclusions. Please contact the Fund for more information. 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.
Schedule of Benefits
Maximum Amount Payable
The maximum amount payable for each individual for the listed dental services will be $2,750 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.
General Limitation of Covered Expenses
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.