DC 37 DENTAL BENEFIT
THE DENTAL FUND TABLE OF CONTENTS
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1. MANDATORY PRE-AUTHORIZATION
2. CLAIM
FORMS
4. GUIDELINES FOR
THE PLANS' DENTAL SERVICES
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
New Dental claim
forms (pdf format*) are now
available at the Plan office. The new form is a one-page claim form, with information about
filing claims on the back in both English and Spanish. The new form has two
sections, one to be completed by the member and the second, to be completed by
the dentist. All required signatures are now 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 may 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 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
- 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. or License Number of the
dentist
- Signatures of dentist and member
- CDT-4 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 (application of stannous or sodium
fluoride) 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
Orthodontia Benefit Dollars: The lifetime maximum for orthodontia benefit
is:
1) $1500 for work started after
2) For work started after
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
stannous and sodium fluoride are not payable for persons over 18 years of
age.
- Stannous and sodium 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
- 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.
The following is a statement
of the policies of the Dental Centers. This policy 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.
JORALEMON DENTAL SERVICES, P.C.
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DC 37 Health & Security Plan Rules and regulations limit
your Dental Benefits to $1700 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.
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 elsewhere.
If you are a no-show two (2) or more times for a Specialist appointment, we
will also ask you to seek treatment elsewhere.
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 no-shows.
Cancellations
- A minimum of
24-hours notice is required for an appointment to be canceled without penalty.
Anything less than 24 hours notice will be considered a no-show.
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.
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 that 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.
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 do not render treatment to
patients who have implants. If you are a patient at the Center and you decide
to have an implant, you will be asked to have all of your future treatment
performed outside the Center.
We offer the 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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