Dental Plan
Your plan year is from June 1 – May 31. All claims must be submitted within 90 days of the close of your “Plan Year” (by August 31).
Time restrictions apply to certain procedures. Please consult the Covered Dental Services sectionof your plan booklet for details.
You must submit a pre-treatment estimate for any claim expected to exceed $500.00 in cost.
****PRE-TREATMENT ESTIMATES****
X-RAYS AND/OR PERIO CHARTING ARE REQUIRED FOR:
PROSTHETICS
ENDODONTICS
PERIODONTICS
COORDINATION OF BENEFITS
If you or your spouse each has coverage, the plan considered primary for the dependent childrenis that of the parent whose month and day of birth occur earliest in the calendar year.
When you submit claims for members of the family who are primary through another carrier, acopy of the primary plan payment must accompany the claim.
Amount of Benefits
The amount of benefits available to you for specific procedures will be in accordance with theschedule of fees adopted by the fund trustees.
Benefits payable to an eligible participant and dependents is limited to $3,000 (effective 6/1/18)per individual in any one fiscal year (June 1 – May 31).
The maximum life-time benefit for orthodontic treatment is $5,000 (effective 7/1/24). For active members only.
Adult orthodontia is covered if one of the following conditions exists:
- Extreme bucco-lingual version of teeth, either unilateral or bilateral.
- A protrusion of maxillary teeth of more than 4mm.
- A protrusive relation of the maxillary or mandibular arch of at least on cusp.
- An arch length discrepancy of 4 or more mm.
- Straighten and correct teeth crowding of upper and lower arch.
DESCRIPTION OF DENTAL PLAN BENEFITS
The following benefits are payable, subject to the other provisions and limitations of the plan, for “Covered Dental Services.”
A. AMOUNT OF BENEFITS
When an eligible Participant and his/her lawful dependents have incurred covered dental charges for services, supplies or treatment furnished, the fund will pay an amount of benefits up to 100% of the scheduled allowance.
B. MAXIMUM BENEFITS
Benefits payable to an eligible participant and dependents in any plan year are limited. PLEASE SEE THE BENEFITS SUMMARY FOR THE CURRENT MAXIMUM AMOUNT.
BENEFIT DETERMINATION
The Plan covers treatment performed while covered. Treatment will be considered to have been performed for the listed procedure as follows:
A. Dentures, full or partial –when impression is taken for the appliance.
B. Fixed bridgework, crowns and gold restorations –when the tooth is first prepared.
C. Root canal therapy –when tooth is opened.
D. Orthodontics –when the first appliance is installed.
LIMITATIONS AND EXCLUSIONS APPLICABLE TO DENTAL BENEFITS PLAN
“Covered Dental Charges” shall in no event be deemed to include expenses incurred for the services, supplies or treatment:
A. Unless such services, supplies or treatment were prescribed as necessary by a dentist or physician.
B. In a Veteran’s Administration Hospital, or which in the absence of coverage, would have been furnished without cost, or are furnished under conditions where the covered individual has no legal obligations to pay, or if the expenses are reimbursable by a local or other governmental agency.
C. Covered under any group program or union, employer or association program to the extent that more than 100% recovery by the participant would be made for any charges for which benefits are provided hereunder.
D. Covered under the U.S. Social Security Act (title XVIII) as amended from time to time.
E. If they were incurred on account of:
(1) War, declared or undeclared, including armed aggression;
(2) Services, supplies or treatment received from a dental or medical department maintained by an employer, a mutual benefit association, labor union, trustee or similar type of group;
(3) Loss or theft of dentures or bridgework;
(4) Dentistry for cosmetic purposes, exclusive of orthodontia, including alteration or extraction and replacement of sound teeth for the purpose of changing appearance;
(5) Bodily injury arising out of and in the course of employment by any employer, or disease or defect with respect to which benefits are payable under any Workers compensation or occupational Disease Act or Law.
F. There are time restrictions indicated in the plan document for certain procedures. All members are expected to adhere to these time restrictions.
G. Crowning of teeth for periodontal support is not covered.
H. Temporary services are not covered expenses.
SUBMISSION OF PRE-TREATMENT ESTIMATES
A treatment plan, with respect to a course of services or treatment, that is expected to exceed $500.00 in cost must be submitted to the plan within 20 days following the examination which reveals the need for such services or treatment. Such treatment plan MUST include appropriate X-rays, a description of services to be furnished, as well as an explanation of the need for such services or treatment. The Pre-treatment estimate shall be submitted on official claim forms. With the exception of emergency work, failure to obtain PRE-APPROVAL could result in non-payment of claim if need cannot be clearly established.
COVERED DENTAL SERVICES
The Plan covers the following services and supplies, for which a charge is made by a dentist or physician, that are required in connection with the dental care and treatment of any disease, defect or accidental bodily injury.
A. PREVENTATIVE TREATMENT
(1) Prophylaxis (cleaning of teeth) is covered four times during each plan year. The plan will not cover a prophylaxis within 30 days of a full-mouth periodontal scaling.
(2) Periodontal Maintenance (D4910) is covered up to four times each plan year (in lieu of prophylaxis). The plan will only pay for periodontic maintenance where the individual has been involved with procedures of periodontal curettage or osseous surgery.
(3) A fluoride treatment will be covered once during each plan year for members and dependents.
(4) Sealants on all teeth will be covered once every 36 months for everyone with no age limit.
(5) Space maintainers for children only.
B. EMERGENCY TREATMENT
Emergency visits are covered by the Plan even if no actual dental treatment is provided during the same day. No more than (2) emergency treatments will be covered in any one plan year.
C. DIAGNOSTIC SERVICES
The Plan covers oral examinations, X-rays and laboratory tests that may be necessary to diagnose a specific symptom.
(1) Oral examinations are covered twice per plan year
(2) Four (4) X-Rays will be allowed for any one oral examination
(3) Full mouth series of X-Rays is covered once in a 3 year period
(4) Panoramic film is covered upon need
The plan will cover no more than four (4) X-Rays for any one oral examination. However, a full mouth X-Ray of all teeth taken as part of a general examination is covered once in a three year period. Allowances for films or other procedures covered by the Plan include the charge for examination and diagnosis. Oral exams are covered twice per plan year.
D. ANESTHETICS
A separate charge for general anesthesia is only covered in conjunction with partial and full bone extraction, osseous surgery, fractures or dislocation. A charge for local anesthesia is not covered as it is included within the normal charge for the treatment for which the local is given.
E. DRUGS
The Plan covers charges for injectable antibiotics administered by a dentist or physician.
F. EXTRACTIONS AND ORAL SURGERY
The Plan covers all extractions and/or other necessary oral surgery including fractures and dislocations. Allowances for extractions and oral surgery procedures include routine post-operative care. The plan covers oral surgery related to the excision of tumors and/or cysts which are located on the teeth, gum tissue and the alveolus surrounding the teeth. Claims for extraction of wisdom teeth must be accompanied by X-Rays of the area in question.
G. FILLINGS
The plan covers fillings that are necessary to restore the structure of teeth that have broken down by decay or traumatic injury. This includes all silver (amalgam) and composite fillings. Fillings involving the same surfaces are not covered within two (2) years of date of service.
H. CROWNS/ONLAYS AND INLAYS
Crowns that are necessary to restore the structure of teeth that have been broken down by decay or traumatic injury and cannot be reconstructed by a filling or other material are covered. This includes gold, porcelain and plastic restorations. Gold onlays and inlays are also covered if the tooth cannot be reconstructed by a filling of other material. Crowning of teeth for periodontal support is not covered. Replacement crowns and onlays or inlays are not covered within five (5) years of prior placement.
I. TREATMENT OF GUM DISEASE-PERIODONTICS
The Plan covers necessary periodontal treatment of the gums and supporting structure of the teeth. THE PLAN WILL PAY FOR TWO (2) PERIODONTAL SCALINGS PER YEAR. Periodontal maintenance and perioprophy will be counted as preventive care, which is covered twice per year. The plan will only pay for periodontic maintenance (04910) where the individual has been involved with procedures of periodontal curettage or osseous surgery. (SEE PREVENTIVE PRETREATMENT).
In the event that the plan is billed for full-mouth periodontal scaling, curettage and osseous surgery, the plan will not pay for periodontal curettage. Major periodontal work must be pre-approved with supporting x-rays and charting. Osseous surgery will not be covered within five (5) years of the last treatment.
J. ROOT CANAL THERAPY
The plan covers root canal and other endodontic treatment. All services provided that are normally associated with root canal therapy are included in the scheduled fee.
K. ORTHODONTICS
There is a LIFE-TIME ORTHODONTIC BENEFIT. PLEASE SEE THE BENEFITS SUMMARY FOR THE CURRENT MAXIMUM AMOUNT. (Retirees and their dependents are not eligible for Orthodontic treatment).
ADULT ORTHODONTIA IS NOW COVERED IF ONE OF THE FOLLOWING CONDITIONS EXIST:
(1) Extreme bucco-lingual version of teeth, either unilateral or bilateral;
(2) A protrusion of maxillary teeth of more than 4 mm.;
(3) A protrusive relation of the maxillary or mandibular arch of at least one cusp;
(4) An arch length discrepancy of 4 or more mm.
(5) Straighten and correct teeth crowding of upper and lower arch
Payment will be made for active monthly treatment only. Retainers are considered part of the total treatment plan, and therefore are not a separate expense.
If a new member’s dependent child is already in orthodontic treatment on the date they become eligible for orthodontic coverage, the following formula will apply. Twenty-four (24) months will be considered a full case. The Plan will subtract the number of months already in treatment from 24 and pay the maintenance allowance for the remaining months.
L. PROSTHETICS
The plan covers prosthetic appliances (full denture, partial removable or fixed bridgework). The Plan will not cover the initial placement of appliances involving teeth extracted prior to coverage. However, the Plan will cover dentures or fixed bridges that replace an existing appliance even if the teeth are not extracted while covered, if the prior appliance is more than five (5) years old and cannot be made satisfactory. Where teeth are being replaced within the same arch, but not within the same quadrant, an allowance for a partial will be made and not for fixed bridgework. The plan also includes benefits for repairing damaged dentures or adding teeth to existing dentures or rebasing the denture. If the plan pays for a new denture, it will not also cover the repair or rebasing of an old denture. Reliners are not covered within the first six (6) months from the date of placement, and are not covered more often than once per plan year. The Plan does not cover precision or semi-precision attachments. The Plan will not cover replacement of prosthetic appliances in less than five (5) years for any reason.
NOTE: NEW MEMBERS ARE NOT COVERED FOR PROSTHETICS FOR ONE YEAR.
M. TEETH WHITENING
The plan covers teeth whitening once every 5 years. This benefit is available to the employee and spouse only.
DEFINITIONS
A. DENTIST - The term “dentist” shall be deemed to mean a Doctor of Dental Surgery or Doctor of Medical Dentistry.
B. DENTAL SERVICE - The term “dental service” means any service listed in the Schedule of Covered Dental Services when performed by or under the direction of a licensed dentist.
C. COVERED DENTAL EXPENSE - Means the expense actually incurred for charges made by a dentist for the performance of a dental service when such service is essential for the necessary care of teeth.
D. PLAN YEAR – JUNE 1ST. to MAY 31ST.
HOW TO FILE A DENTAL CLAIM
Step 1 -
Member (or dependent) to present the Anthem Card at time of dental visit to provider:
Dental Claims
Send to:
Anthem
PO Box 659444
San Antonio, TX 78265
Step 2 -
Members: Then submitting inquiries always include your account number from the face of this card. Possession or use of this card does not guarantee payment. Complete the "Patient" statement in full. If all questions are not answered, it will be necessary to return the claim form, which will delay benefit payment.
Step 3 -
Dental Inquiries:
The Preferred Group
Benefit Services
866-989-8997
NOTE: SEND ALL CLAIM FORMS PROMPTLY. CLAIM FORMS MUST BE FULLY COMPLETED BY ALL PARTIES CALLED FOR AND SUBMITTED WITHIN 90 DAYS FROM THE CLOSE OF THE PLAN YEAR. IMPROPERLY COMPLETED FORMS WILL CAUSE A DELAY IN THE PAYMENT OF A CLAIM.
Proper consideration can only be given to a claim when the completed form is received.
All claim inquiries should be directed to Preferred Group. Office hours are 8:00 a.m. to 4:30 p.m.
COMMON CLAIM PROBLEMS
A. Incomplete information regarding whether you or your spouse has other group insurance coverage, and if so, name of insurance company, address, policy number, etc. If there is other group coverage, send a copy of the benefit payment record furnished by the other plan.
B. Incomplete information regarding dates of birth or age.
CLAIM PROCESSING
Examination - The Trust, at its own expense, shall have the right and opportunity to examine any member as often as it may reasonably require during the review and processing of the claim.
