DENTAL BENEFITS

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AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES / AFL-CIO

DC 37 DENTAL BENEFIT

teethclean

THE DENTAL FUND TABLE OF CONTENTS

(Click any green link in the Table of Contents to jump to that document)

1. MANDATORY PRE-AUTHORIZATION

2. CLAIM FORMS

3. CONTINUATION OF TREATMENT

4. GUIDELINES FOR THE PLANS' DENTAL SERVICES

5. COVERAGE EXCLUSIONS

6. DENTAL FEE SCHEDULE

7. DENTAL CENTER POLICIES

8. LIST OF DENTAL PROVIDERS (ACROBAT READER REQUIRED)

Please contact the Inquiry Unit at 212-815-1234 to determine your eligibility for this benefit and your benefit plan allowances.

Members who are eligible for a full dental benefit will be covered for 100% of the dental fee schedule. If you use a non-participating provider, you will be responsible for any difference between the Plan's fee schedule and the dentist's actual charges.

Members who are eligible for a partial dental benefit will be covered for 75% of the dental fee schedule and will be responsible for the additional 25%. If you use a non-participating provider, you will be responsible for any difference between the Plan's fee schedule and the dentist's actual charges, in addition to the 25% of the allowable amount.

In all cases should you obtain treatment that is restricted, has a frequency limitation, is a non-covered procedure or if you go over the yearly maximum, you will be responsible for any additional costs incurred.The yearly maximum benefit is $1,700 per calendar year, based on the Plan's fee schedule. In all circumstances, Plan rules regarding restrictions, limitations, and annual dollar limit will apply.

Mandatory Pre-Authorization

Pre-authorization is mandatory before beginning treatment for prosthetics (dentures and bridgework), single crowns, extensive gum treatment, TMJ therapy, root canal therapy or orthodontics. YOU MUST submit a Pre-Authorization Plan.

This pre-authorization is for your benefit. You get a free second professional opinion to determine if the work is necessary. In addition, you will have advance notice of the extent of the work involved- dentally and financially.

YOU MUST SUBMIT A PRE-AUTHORIZATION PLAN FOR THE ABOVE LISTED SERVICES OR YOUR CLAIM WILL BE REJECTED.

On the appropriate form, available at the Plan Office, your dentist will describe the proposed work, and attach x-rays to show that the work is needed.

You and your dentist should complete the form and send it to the Plan Office. The Plan Office reviews the pre-authorization plan, then notifies you and your dentist if the intended work is covered and for how much. THIS ASSUMES, OF COURSE, THAT YOU ARE ELIGIBLE FOR BENEFITS WHEN THE WORK IS PERFORMED, and takes into consideration the Plan's rules and regulations regarding yearly maximums and frequency limitations for certain procedures. There are no appeals for proposed treatment (pre-authorization) that have been rejected by the Plan. If the dentist disagrees with the treatment authorized in the pre-authorization response, the dentist should write to the Professional Review Unit and send in any additional information justifying why he/she thinks the procedure should be done.

New Dental Claim Forms

The Dental Unit can accept both DC 37 Dental claim forms (pdf format*) as well as universal claim forms from your dentist's office. DC 37 claim forms are available at the Plan office. The form is a one-page claim form, with information about filing claims on the back in both English and Spanish. The form has two sections, one to be completed by the member and the second, to be completed by the dentist. All required signatures are located at the bottom of the claim form. The member and dentist sign only one box, whether the claim is for a Pre-Authorization or Claim for Completed Services. For claims for completed services, the member must indicate that the payment be made to either the member or dentist by checking the appropriate box. You download claim forms here (pdf format*) or request the forms be sent to you by calling the Plan's Inquiry Unit at the Forms Only line at (212) 815-1531.

Claims

If treatment does not need pre-authorization, the member should submit the claim form (pdf format*) signed by the member and the dentist with the proper address within 30 days of completion of treatment.
If a pre-authorization was submitted, the claim for payment should be returned on the computer generated pre-authorization form after the dentist inserts the dates of treatment. The member and the dentist should sign the claim form. BEFORE THE MEMBER SIGNS THE CLAIM FORM, HE/SHE SHOULD BE SURE THAT ALL THE PROCEDURES, SIGNED FOR, WERE DONE. REMEMBER THAT MEMBERS WILL BE HELD RESPONSIBLE FOR ALL TREATMENT BILLED WHETHER ACTUALLY PROVIDED OR NOT. IF THE PLAN IS BILLED, THE APPROPRIATE RESTRICTION WILL BE PUT IN PLACE. If only a partial payment is requested, the member still has to submit a claim on the same computer-generated form. A new pre-authorization form will be generated by the computer, and sent to the member and the dentist, for the rest of the work.
If information is missing from the claim relating to the treatment, or if additional treatment was done that was not pre-authorized, the claim may be pended. The member and the dentist will then be informed why the claim was not paid and the dentist will be requested to provide us with the necessary information so that payment can be made.
When resubmitting a claim, please submit original claim forms with original signatures - photocopies of signatures and claim forms are not acceptable for payments.

It's the member's responsibility to make sure that the dentist completes and signs his/her portion of the claim and that the form is submitted within 30 days after the completion of work. All pre-authorizations and claims should contain:

Member's Social Security number
Tax I.D. of the dentist
Signatures of dentist and member
CDT 2007/2008 Codes
Treatment descriptions, tooth #'s and quadrants
Complete patient information

If any of the above information is omitted, the pre-authorization or claim cannot be processed and will be returned to the member or dentist.

Continuation of Treatment

If you are terminated from employment for any reason except total disability- (members receiving Disability Benefits are eligible for Health & Security Plan benefits up to a maximum of three months for part time benefits or six months for full time benefits, from the date of their disability)- while you are having dental work done, the Plan will continue to cover certain services* already begun up to 60 days after termination. This is also true for your spouse and eligible dependents.

* Only Orthodontics, prosthetics or root canal therapy.

Inquiries

For information relating to dental pre-authorizations and claims, you should contact the Inquiry Unit at 212-815-1234.Effective 10/1/2001 increases were made in the DC 37 Health & Security Plan's dental fee schedule. The increase in reimbursement, both at the member and participating level, will apply to oral surgery, bridges, dentures and endodontics. The yearly maximum benefit was increased as well, from $1,500 to $1,700.

Guidelines of the Plan's Dental Services

Regular Examinations and Cleaning: Once every six months, measured from the date of service, you (and eligible dependents) can have your teeth examined by a licensed dentist to check for cavities and other dental or oral problems. You can also have your teeth cleaned and scaled once every six months.

Diagnostic X-Rays: You can have your whole mouth x-rayed as a double check on possible dental problems once every two (2) consecutive calendar years. There is a $50 maximum x-ray benefit for the two years. This does not apply to x-rays necessary to diagnose a specific disease or injury or to determine progress in its treatment.

Benefits will be available for any post operative x-rays (except in root canal therapy) whenever it is requested by the Plan to help in an evaluation. The amounts that will be paid for individual x-rays are listed in the Plan's Dental Fee Schedule.

Fluoride Treatments: Once every six months, measured from the date of service, your children (18 years of age and under) can receive fluoride treatments to help prevent tooth decay.

Emergency Treatment: You are covered for treatment to alleviate pain when a toothache occurs.

Fillings: To repair decayed teeth.

Extractions: And other oral surgery covered as required.

Crowns (caps), Bridgework & Dentures: Crowns, bridgework and dentures are not covered during the first year of employment unless it is replacing a tooth, which was extracted while you were a covered individual. Bridgework, dentures and crowns will not be replaced before a five (5) year period has elapsed from the original date of placement. If it becomes necessary to extract the abutment tooth of a bridge during this five (5) year period, the Plan will only pay for the replacement of the tooth providing it can be added to the existing appliance (an abutment tooth is the tooth, which supports
the fixed or partial denture).

Root Canal Therapy: Payment for root canal therapy is once in a lifetime per tooth.

Periodontia: Gum treatments and necessary periodontic care. If you use the periodontal panel or receive periodontal care at one of the dental centers, there is a $10 per quadrant co-payment for periodontal surgery.

Orthodontics: Please contact the Plan office to determine your eligibility for this benefit. Orthodontia coverage is available to members and all dependents covered as part of the active full dental benefit. Orthodontia coverage is not available to members, retirees or dependents covered for a partial dental benefit.Orthodontia coverage is available to dependent children only as part of the retiree full dental benefit.

If you are eligible for an orthodontia benefit, the Plan will pay up to $1840 for this very important aid to dental health. It breaks down this way: The Plan pays up to $400 for diagnosis and the orthodontic appliance, then up to $60 a month for adjustments. The $1840 is a lifetime maximum for the orthodontia benefit for treatment started after 10/01/01.

Orthodontia Benefit Dollars: The lifetime maximum for orthodontia benefit is:
1) $1500 for work started after January 1,1990 up to September 30, 2001.
2) For work started after October 1, 2001, the lifetime maximum is $1840.
The start date is the date the appliance is inserted.

In all circumstances, Plan rules regarding restrictions, limitations, and annual dollar limit will apply.

Coverage Exclusions

What the Plan does not pay for:

In general, any dental work begun before you become eligible for dental benefits will not be covered, even if completed after you become eligible. For example, if a root canal was opened before becoming eligible, the root canal therapy will not be covered even if done at a later date. If you have a tooth prepared for a cap before becoming eligible, the cap is not covered even if it is put on after eligibility is established.
Benefits are not payable for more than one examination and cleaning in any six consecutive months.
The Plan does not pay an additional fee for the completion of forms.
Benefits are not payable for a prophylaxis rendered the same day as a periodontal treatment.
Benefits for topical application of fluoride are not payable for persons over 18 years of age.
Fluoride treatments for persons under 18 years of age are not payable more than once every six months.
Occlusal adjustments are limited to one full mouth adjustment every five years, effective January 3,1994.
No additional allowance will be provided to connect or disconnect units involved in fixed bridgework.
Benefits are not payable for temporary crowns unless necessitated by an accidental injury to natural teeth.
A temporary restoration (except when necessitated by accidental injury) is considered part of and is included in the allowance for the final restoration.
No additional benefits will be provided for postoperative treatment.
Payment is limited to: a) two pins per tooth, b) $55 filling benefit per tooth.
Benefits are not payable beyond a maximum of $1700 per covered individual per calendar year.
Benefits are not payable for the following services to a covered individual, such as: (i) an appliance, or modification of an appliance, for which an impression was made before the person became a covered individual, or (ii) a crown, bridge or gold restoration, for which a tooth was prepared before the person became a covered individual, or (iii) root canal therapy, for which the pulp chamber was opened before the person became a covered individual.
Benefits are not payable for a partial or full removable denture or fixed bridgework if it involves replacement of one or more natural teeth extracted prior to the employee being in a covered job title for a consecutive 12 month period, unless the denture or fixed bridgework also includes replacement of a natural tooth, which (i) is extracted while the person is such a covered individual and (ii) was not an abutment to a partial denture or fixed bridge installed within the immediately preceding five years.
Benefits are not payable for a new partial or full removable denture or fixed bridgework, or a crown or gold restoration, if it involves the replacement of a denture, bridgework, crown or gold restoration which was inserted during the immediately preceding five years.
Benefits are payable for a precision denture up to the maximum scheduled benefit allowable for a cast or acrylic base partial denture with a gold or chrome lingual or palatal bar with two clasps. However, crowns inserted as abutments for precision or semi-precision attachment appliances and cast or acrylic based partial dentures are not covered except where necessitated by either periodontics or restorative reasons.
Adjustments to dentures and space maintainers are considered part of the allowance if made within four months of installation. The relining of an immediate denture will be considered after four months from the insertion date. An office reline will be limited to once every twelve (12) months. A laboratory reline will be limited to once every twenty-four (24) months.
Any service not listed in the Plan's fee schedule will be excluded except as follows: If a charge is incurred for a service not included in the schedule, in connection with the dental care of a specific covered condition, and if the schedule contains one or more services which, according to customary dental practices, are in the Plan's opinion, appropriate for the dental care of that condition, then a charge for the least expensive of such services as are included in the Schedule will be considered to have been incurred in lieu of the charge actually incurred.
Expenses incurred after the termination of a person's coverage are not reimbursable except as applicable under the Continuation of Treatment Provision.
Charges in excess of the scheduled fee shown in the Plan's benefit schedule.
Charges for procedures rendered before a person becomes eligible for benefits.
A service not reasonably necessary, or not customarily performed, for the maintenance of the patient's health.
A service furnished a person for cosmetic purposes, unless necessitated as a result of an accidental injury sustained while the person was a covered individual.
Facing on crowns, or pontics, which are posterior to the first molar are considered cosmetic and are excluded in accordance with paragraph 24 above.
Any employment related disease or injury to the teeth, which is covered by any Workers' Compensation law, occupational disease law, or similar legislation.
A service or supply (i) furnished by or for the U.S. Government, (ii) furnished by or for any other government unless payment is legally required, or (iii) to the extent any benefit is provided by any law or government program under which the person is or could be covered.
Charges covered by another group dental insurance plan.
Replacement of lost or stolen appliances.
Any dental service which is not furnished by a licensed dentist, unless performed by a licensed dental hygienist under the supervision of a dentist or is an x-ray ordered by a licensed dentist.
Services covered by any other medical or surgical benefit or insurance program.
Charges for oral hygiene instruction, dietary planning, etc.
Dental supplies, including, but not limited to, toothbrushes, toothpaste, mouthwash, water-piks, etc. are not covered by the dental benefit.
Payment for periodontal surgery is restricted to once every five years. Each quadrant will be considered individually.

Dental Centers

In addition to using any licensed dentist or a dentist from the Plan's list of Participating Panel Dentists, a member and/or dependents may also obtain treatment at either of the two dental centers. The same Plan rules regarding: restrictions, limitations and/or annual dollar limit will also apply. The individual who obtains treatment at the Plan's Centers will be required to comply with the policies and regulations established by the Center for its patients.

Active and retired members covered by the DC 37 New York Public Library Health and Security Plan Trust and the DC 37 Cultural Institutions Health and Security Plan Trust are not eligible for dental services at 115 Chambers Street and 186 Joralemon Street.

Dental Center Policies

JORALEMON DENTAL SERVICES, P.C.

Manhattan Center
115 Chambers Street
New York, NY 10007
(212) 766-4440

Brooklyn Center
186 Joralemon Street
Brooklyn, NY 11201
(718) 852-1400

The following is a statement of the policies of the Dental Centers. This policy statement is distributed to each patient at his or her initial appointment. It is expected that each patient will sign this statement before dental treatment begins.

DC 37 Health & Security Plan Rules and Regulations limit your Dental Benefits to $1,700 per year based on the Plan's fee schedule. Expenses indicated on your Explanation of Benefits (EOB) Statement as "Balance Due" are the member's responsibility, whether or not you were informed prior to treatment. To avoid problems, please discuss your treatment with your Dentist or Treatment Plan Coordinator.

When your first appointment is scheduled, you will be assigned to a general dentist. Due to the volume of patients seen at the Center, it is not feasible to have patients select their own dentist. The dentist will refer the patient to the hygienist. If necessary, specialty care will be provided for active patients of the Centers.

All visits are by appointment only. Emergency visits are also by appointment and are not treated on a walk-in basis. If you have an emergency, you must call the Center early in the day. The screening dentist will advise you how to proceed.

The Centers render limited treatment on a case by case basis to patients who have implants.

No-Shows - A patient will be considered a "no-show" if s(he) fails to appear for a scheduled appointment, or gives the Center less than 24 hours notice to cancel an appointment. If three (3) or more no-shows occur, we will ask you to seek dental treatment outside of the Center. If you are a no-show two (2) or more times for a Specialist appointment, we will also ask you to seek treatment outside of the Center.

Lateness - Patients are seen by appointment only and time is allocated based upon the procedure(s) to be completed. If a patient is late for his or her appointment, we may not have sufficient time to do the scheduled work. In these cases, we reserve the option to reschedule your appointment. Habitual lateness will be treated as a no-show.

Cancellations - A minimum of 24-hours notice is required for an appointment to be cancelled. Anything less than 24 hours notice will be considered a no-show.

Maintaining your status as an active patient requires your cooperation. The Center provides comprehensive general dentistry and recommends that patients return each year for a dental check up. If more than two years lapse, you will not be given an appointment until you again place your name on the waiting list. We do not co-treat patients who are in active dental treatment outside of the Center, except for orthodontics.

We offer these explanations of our policies to assist you. It is not possible for us to address each individual's specific circumstances. You are encouraged to ask questions for further clarification.

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