Basic Restorative Benefits - Exclusions and Limitations. If the fee for a procedure or service is “Disallowed”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee. • If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan. 1. Resin (white) or amalgam (silver) restorations (fillings) are a covered benefit once per tooth surface in a period of twenty-four (24) months, irrespective of the number or combination of procedures performed. Charges for the replacement of silver or white fillings within twenty-four (24) months by the same Dentist/dental office is Disallowed. 2. Resin restorations in posterior teeth (white fillings in bicuspids and molars) are optional. If a resin restoration is performed on posterior teeth, other than the buccal surface of bicuspids, an allowance will be paid equal to an amalgam (silver) restoration, and the patient is responsible for any additional fee. 3. Resin based composite crowns on front teeth are a covered benefit once in a period of two (2) years per tooth for patients age twelve (12) and older. Fees are Disallowed if replaced within two (2) years by the same Dentist/dental office. 4. An adjustment will be made for two (2) or more restoration surfaces which are normally joined together. A Participating Dentist agrees not to charge a separate fee. 5. Prefabricated stainless steel crowns are a covered benefit once in a period of twenty-four (24) months. The fee for replacement of a stainless steel crown by the same Dentist/dental office within twenty-four (24) months is included in the initial crown placement. A separate fee is Disallowed. 6. Prefabricated porcelain crowns are a covered benefit on primary teeth only, once in a period of twenty-four
Appears in 1 contract
Samples: Member Benefit Agreement
Basic Restorative Benefits - Exclusions and Limitations. If the fee for a procedure or service is “Disallowed”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee. • If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan.
1. Resin (white) or amalgam (silver) restorations (fillings) are a covered benefit once per tooth surface in a period of twenty-four (24) months, irrespective of the number or combination of procedures performed. Charges for the replacement of silver or white fillings within twenty-four (24) months by the same Dentist/dental office is Disallowed.
2. Resin restorations in posterior teeth (white fillings in bicuspids and molars) are optional. If a resin restoration is performed on posterior teeth, other than the buccal surface of bicuspids, an allowance will be paid equal to an amalgam (silver) restoration, and the patient is responsible for any additional fee.
3. Resin based composite crowns on front teeth are a covered benefit once in a period of two (2) years per tooth for patients age twelve (12) and older. Fees are Disallowed if replaced within two (2) years by the same Dentist/dental office.
4. An adjustment will be made for two (2) or more restoration surfaces which are normally joined together. A Participating Dentist agrees not to charge a separate fee.
5. Prefabricated stainless steel crowns are a covered benefit once in a period of twenty-four (24) months. The fee for replacement of a stainless steel crown by the same Dentist/dental office within twenty-four (24) months is included in the initial crown placement. A separate fee is Disallowed.
6. Prefabricated porcelain crowns are a covered benefit on primary teeth only, once in a period of twenty-fourfour (24) months.
7. Recementation of a metallic inlay or onlay, or a crown or partial coverage restoration is a covered benefit once in a lifetime. Payment for recementation of an inlay or onlay, crown or partial coverage restoration is Disallowed when performed within six (6) months of the initial placement by the same Dentist/dental office.
8. Payment is made for one (1) restoration in each tooth surface irrespective of the number of combinations of restorations placed. A Participating Dentist agrees not to charge a separate fee.
9. Fees for protective restorations are Disallowed if performed on the same date of service as a palliative treatment by the same Dentist/dental office.
10. A Routine cleaning is included in a full mouth debridement and a periodontal maintenance cleaning. As a result, each of these procedures is counted toward your cleaning benefit of once in a six (6) month period.
11. A cleaning done on the same date by the same Dentist/dental office as a periodontal maintenance, or scaling and root planing is considered to be part of and included in those procedures. The fee is Disallowed.
12. Fees for periodontal maintenance are Disallowed when billed within three (3) months of periodontal therapy by the same Dentist/dental office.
13. Periodontal scaling and root planing is a covered benefit per quadrant once in a period of twenty-four (24) months. Benefits are paid for a maximum of two (2) quadrants per office visit. Fees are Disallowed for twenty-four (24) months after the initial therapy if the retreatment is performed by the same Dentist/dental office. If treatment is done by a different Dentist within twenty-four (24) months, benefits are Denied. The patient is responsible for the fee.
14. A partial pulpotomy is a covered benefit, once per tooth per lifetime, on permanent teeth only. The fee for a partial pulpotomy is Disallowed if performed within forty-five (45) days on the same tooth by the same Dentist/dental office as root canal therapy.
15. Pulpal therapy is a covered benefit once in a three (3) year period per tooth on primary first and second molars only. If pulpal therapy is performed on primary anterior or permanent teeth, the procedure will be covered as palliative treatment.
16. Therapeutic pulpotomy is a covered benefit once in a three (3) year period per tooth on primary teeth only. If the service is provided on permanent teeth, the procedure will be covered as palliative treatment.
17. Pulpal debridement is a covered benefit once in a lifetime. The fee for pulpal debridement is Disallowed if performed within thirty (30) days of a root canal treatment by the same Dentist/dental office.
18. Routine post-operative visits are considered part of, and included in the fee for, the total procedure. A Participating Dentist agrees not to charge a separate fee.
19. Pin retention is a covered benefit once per tooth in a period of twenty-four (24) months in conjunction with all restorations. Fees for additional pins in the same tooth are Disallowed. The fee for pin retention is Disallowed when billed in conjunction with a core buildup.
20. Post-operative treatment of complications from oral surgery is a covered benefit once per surgical site, subject to a dental consultant’s review. The fee for post-operative treatment of complications is Disallowed if performed within thirty (30) days by the same Dentist/dental office as the oral surgery.
21. The fee for removal of residual tooth roots is Disallowed when performed on the same date of service as an extraction by the same Dentist/dental office.
22. Alveoplasty is included in the fee for surgical extractions. Separate fees for these procedures are Disallowed if performed by the same Dentist/dental office in the same surgical area on the same date.
23. A frenulectomy or frenuloplasty is a covered benefit once per site per lifetime. The fee is Disallowed when billed on the same date as any other surgical procedure in the same surgical area by the same Dentist/dental office.
24. Reattachment of a tooth fragment, including the incisal edge or cusp, is a covered benefit. Payment is Disallowed in performed within twenty-four (24) months of a restoration on the same tooth by the same Dentist/dental office.
25. An internal root repair is a covered benefit once in a lifetime on permanent teeth only. If performed on a primary tooth, the benefit is Denied. The free for an internal root repair is Disallowed if performed on the same date of service by the same Dentist/dental office as a apicoectomy or retrograde filling.
26. A consultation performed by a Dentist who is not performing further services is a covered benefit. The fee for a consultation is Disallowed if performed in conjunction with an oral evaluation by the same Dentist/dental office on the same date of service.
27. Exploratory surgical services are not a covered benefit. The patient is financially responsible.
28. General anesthesia is covered benefit only when administered by a properly licensed Dentist in a dental office with covered oral surgical procedures or when necessary due to concurrent medical conditions. Otherwise, the fee for general anesthesia is Xxxxxx.
29. The fee for repairs of a complete or partial dentures cannot exceed half the fee for a new appliance. Any excess fee billed by the same Dentist/dental office on the same date of service is Disallowed.
30. Fees for adjustments or repairs of complete or partial dentures, if performed within six (6) months of initial placement by the same Dentist/dental office are Disallowed.
31. Adjustment or repair of a denture is a covered benefit twice in a twelve (12) month period. Fees for an adjustment or repair of a denture is Disallowed if performed within six (6) months of initial placement. The fee for an adjustment or repair of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
32. The relining of a denture is a covered benefit two (2) times in a period of twelve (12) months. The fee for reline of a denture cannot exceed one-half of the fees for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
33. The rebase of a denture is a covered benefit once in three (3) years. The fee for rebase of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
34. The fee for a reline or rebase of a denture is Disallowed if performed within six (6) months of initial placement by the same Dentist/dental office.
35. Rebase and reline include adjustments required within six (6) months of delivery. When an adjustment is billed within six (6) months of a rebase or reline by the same Dentist/dental office, fees for the adjustment are Disallowed.
36. Recementation of a fixed partial denture is a covered benefit once in a period of twelve (12) months. Fees for recementation of fixed partial dentures are Disallowed if done within six (6) months of the initial placement by the same Dentist/dental office.
37. Cleaning and inspection of a removable complete or partial denture is not a covered benefit. The fee for cleaning and inspection of a removable complete or partial denture is Disallowed when done by the same Dentist/dental office, or if performed on the same date of service as a reline or rebase of the denture. Otherwise, the fee for cleaning and inspection of a removable complete or partial denture is Denied.
38. Bone replacement graft for ridge preservation is a covered benefit, once per site per lifetime.
39. Recementation of a prefabricated post and core is a covered benefit once per tooth per lifetime. Payment is Disallowed if performed within six (6) months of the initial placement by the same Dentist/dental office, or if performed on the same date of service of a crown recementation by the same Dentist/dental office.
40. Tissue conditioning is a covered benefit two (2) times in a three (3) year period. The fee for tissue conditioning is not a benefit if performed on the same day the denture is delivered or a reline/rebase is provided by the same Dentist/dental office and is Disallowed.
41. Tooth preparation, bases, copings, protective restorations, impressions, and local anesthesia, or other services that are part of the complete dental procedure, are considered components of, and included in the fee for, a complete procedure. Separate fees are Disallowed.
42. Therapeutic drug injections are a covered benefit subject to a dental consultant’s review.
43. Local anesthesia in conjunction with any procedure by the same Dentist/dental office is considered part of the overall procedure. Separate fees are Disallowed.
44. Excision of lesions is not a covered benefit. The patient is financially responsible. 45. Interim caries arresting medicament application is not a covered benefit.
Appears in 1 contract
Samples: Member Benefit Agreement
Basic Restorative Benefits - Exclusions and Limitations. If the fee for a procedure or service is “DisallowedNot Billable to the Patient”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee. • If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan.
1. Resin (white) or amalgam (silver) restorations (fillings) are a covered benefit once per tooth surface in a period of twenty-four (24) months, irrespective of the number or combination of procedures performed. Charges for the replacement of silver or white fillings within twenty-four (24) months by the same Dentist/dental office is DisallowedNot Billable to the Patient.
2. Resin restorations in posterior teeth (white fillings in bicuspids and molars) are optional. If a resin restoration is performed on posterior teeth, other than the buccal surface of bicuspids, an allowance will be paid equal to an amalgam (silver) restoration, and the patient is will be responsible for any additional fee.
3. Resin based composite crowns on front teeth are a covered benefit once in a period of two (2) years per tooth for patients age twelve (12) and older. Fees are Disallowed Not Billable to the Patient if replaced within two (2) years by the same Dentist/dental office.
4. An adjustment will be made for two (2) or more restoration surfaces which are normally joined together. A Participating Dentist agrees not to charge a separate fee.. SAMPLE
5. Prefabricated stainless steel crowns are a covered benefit once in a period of twenty-four (24) months. The fee for replacement of a stainless steel crown by the same Dentist/dental office within twenty-four (24) months is included in the initial crown placement. A separate fee is DisallowedNot Billable to the Patient.
6. Prefabricated porcelain crowns are a covered benefit on primary teeth only, once in a period of twenty-fourfour (24) months.
7. Recementation of a metallic inlay or onlay, or a crown or partial coverage restoration is a covered benefit once in a lifetime. Payment for recementation of an inlay or onlay, crown or partial coverage restoration is Not Billable to the Patient when performed within six (6) months of the initial placement by the same Dentist/dental office.
8. Payment is made for one (1) restoration in each tooth surface irrespective of the number of combinations of restorations placed. A Participating Dentist agrees not to charge a separate fee.
9. Fees for protective restorations are Not Billable to the Patient if performed on the same date of service as a palliative treatment by the same Dentist/dental office.
10. Interim therapeutic restorations are a covered benefit once in a lifetime on primary dentition only. Interim therapeutic restorations are not a covered benefit when performed within twenty-four (24) months of amalgams or composites and the fees are Not Billable to the Patient.
11. A Routine cleaning is included in a full mouth debridement and a periodontal maintenance cleaning. As a result, each of these procedures is counted toward your cleaning benefit of once in a six (6) month period.
12. A cleaning done on the same date by the same Dentist/dental office as a periodontal maintenance or scaling and root planing is considered to be part of and included in those procedures. The fee is Not Billable to the Patient.
13. The fee for cleanings, scaling in the presence of generalized, moderate or severe inflammation, full mouth debridement and/or periodontal maintenance is Not Billable to the Patient if the services are provided by the same Dentist/dental office within thirty (30) days after the most recent scaling and root planning or other periodontal therapy.
14. Periodontal scaling and root planing is a covered benefit per quadrant once in a period of twenty- four (24) months. Benefits are paid for a maximum of two (2) quadrants per office visit. Fees are Not Billable to the Patient for twenty-four (24) months after the initial therapy if the retreatment is performed by the same Dentist/dental office. If treatment is done by a different Dentist within twenty-four (24) months, benefits are Denied. The patient is responsible for the fee.
15. A partial pulpotomy is a covered benefit, once per tooth per lifetime, on permanent teeth only. The fee for a partial pulpotomy is Not Billable to the Patient if performed within forty-five (45) days on the same tooth by the same Dentist/dental office as root canal therapy.
16. Pulpal therapy is a covered benefit once in a three (3) year period on primary first and second molars only. If pulpal therapy is performed on primary anterior or permanent teeth, the procedure will be covered as a palliative treatment.
17. Therapeutic pulpotomy is a covered benefit once in a three (3) year period per tooth on primary teeth only. If the service is provided on permanent teeth, the procedure will be covered as palliative treatment.
18. Fees for therapeutic pulpotomy or palliative treatment are Not Billable to the Patient when performed on the same date of service as root canal procedure or root canal therapy.
19. Pulpal debridement is a covered benefit once in a lifetime. The fee for pulpal debridement is Not Billable to the Patient when performed in conjunction with endodontic therapy on the same tooth by the same Dentist/dental office.
20. Routine post-operative visits are considered part of, and included in the fee for, the total procedure. A Participating Dentist agrees not to charge a separate fee.
21. Pin retention is a covered benefit once per tooth in a period of twenty-four (24) months in conjunction with all restorations. Fees for additional pins in the same tooth are Not Billable to the Patient. The fee for pin retention is Not Billable to the Patient when billed in conjunction with a core buildup. SAMPLE
22. Post-operative treatment of complications from oral surgery is a covered benefit once per surgical site, subject to a dental consultant’s review. The fee for post-operative treatment of complications is Not Billable to the Patient if performed within thirty (30) days by the same Dentist/dental office as the oral surgery.
23. The fee for removal of residual tooth roots is Not Billable to the Patient when performed on the same date of service as an extraction by the same Dentist/dental office.
24. Alveoplasty is included in the fee for extractions. Separate fees for these procedures are Not Billable to the Patient if performed by the same Dentist/dental office in the same area on the same date.
25. A frenulectomy or frenuloplasty is a covered benefit once per site per lifetime. The fee is Not Billable to the Patient when billed on the same date as any other surgical procedure in the same surgical area by the same Dentist/dental office.
26. Reattachment of a tooth fragment, including the incisal edge or cusp, is a covered benefit. Payment is Not Billable to the Patient if performed within twenty-four (24) months of a restoration on the same tooth by the same Dentist/dental office.
27. An internal root repair is a covered benefit once in a lifetime on permanent teeth only. If performed on a primary tooth the benefit is Denied. The fee for an internal root repair is Not Billable to the Patient if performed on the same date of service by the same Dentist/dental office as an apicoectomy or retrograde filling.
28. A consultation performed by a Dentist who is not performing further services is a covered benefit. The fee for a consultation is Not Billable to the Patient if performed in conjunction with an oral evaluation by the same Dentist/dental office on the same date of service.
29. Exploratory surgical services are not a covered benefit. The patient is financially responsible.
30. General anesthesia is a covered benefit only when administered by a properly licensed Dentist in a dental office with covered oral surgical procedures or when necessary due to concurrent medical conditions. Otherwise, the fee for general anesthesia is Xxxxxx.
31. The fee for repairs of complete or partial dentures cannot exceed half the fee for a new appliance. Any excess fee billed by the same Dentist/dental office on the same date of service is Not Billable to the Patient.
32. Fees for repairs of complete or partial dentures, if performed within six (6) months of initial placement by the same Dentist/dental office, are Not Billable to the Patient.
33. Adjustment or repair of a denture is a covered benefit twice in a twelve (12) month period. Fees for an adjustment or repair of a denture are Not Billable to the Patient if performed within six (6) months of initial placement. The fee for an adjustment or repair of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Not Billable to the Patient.
34. The relining of a denture is a covered benefit two (2) times in a period of twelve (12) months. The fee for reline of a denture cannot exceed one-half of the fees for a new appliance. Any excess fee by the Dentist/dental office is Not Billable to the Patient.
35. The rebase of a denture is a covered benefit once in three (3) years. The fee for rebase of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office is Not Billable to the Patient.
36. The fee for a reline or rebase of a denture is Not Billable to the Patient if performed within six (6) months of initial placement by the same Dentist/dental office.
37. Rebase and reline include adjustments required within six (6) months of delivery. When an adjustment is billed within six (6) months of a rebase or reline by the same Dentist/dental office, fees for the adjustment are Not Billable to the Patient.
38. Recementation of a fixed partial denture is a covered benefit once in a period of twelve (12) months. Fees for recementation of fixed partial dentures are Not Billable to the Patient if done within six (6) months of the initial placement by the same Dentist/dental office.
39. Cleaning and inspection of a removable complete or partial denture is not a covered benefit. The fee for cleaning and inspection of a removable complete or partial denture is Not Billable to the Patient when done by the same Dentist/dental office on the same date of service as a reline or rebase of the denture. Otherwise, the fee for cleaning and inspection of a removable complete or partial denture is Denied.
40. Bone replacement graft for ridge preservation is a covered benefit, once per site per lifetime. SAMPLE
Appears in 1 contract
Samples: Member Benefit Agreement
Basic Restorative Benefits - Exclusions and Limitations. If the fee for a procedure or service is “Disallowed”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee. • If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan.
1. Resin (white) or amalgam (silver) restorations (fillings) are a covered benefit once per tooth surface in a period of twenty-four (24) months, irrespective of the number or combination of procedures performed. Charges Chares for the replacement of silver or white fillings within twenty-four (24) months by the same Dentist/dental office is Disallowed.
2. Resin restorations in posterior teeth (white fillings in bicuspids and molars) are optional. If a resin restoration is performed on posterior teeth, other than the buccal surface of bicuspids, an allowance will be paid equal to an amalgam (silver) restoration, restoration and the patient is responsible for any additional fee.
3. Resin based composite crowns on front teeth are a covered benefit once in a period of two (2) years per tooth for patients age twelve (12) and older. Fees are Disallowed if replaced within two (2) years by the same Dentist/dental office.
4. An adjustment will be made for two (2) or more restoration surfaces which are normally joined together. A Participating Dentist agrees not to charge a separate fee.
5. Prefabricated stainless steel crowns are a covered benefit once in a period of twenty-four (24) months. The fee for replacement of a stainless steel crown by the same Dentist/dental office within twenty-four (24) months is included in the initial crown placement. A separate fee is Disallowed.
6. Prefabricated porcelain crowns are a covered benefit on primary teeth only, once in a period of twenty-fourfour (24) months.
7. Recementation of a metallic inlay, or onlay, or a crown or partial coverage restoration is a covered benefit once in a lifetime. Payment for recementation of an inlay, onlay, crown or partial coverage restoration is Disallowed when performed within six (6) months of the initial placement by the same Dentist/dental office.
8. Payment is made for one (1) restoration in each tooth surface irrespective of the number of combinations of restorations placed. A Participating Dentist agrees not to charge a separate fee
9. Fee for protective restorations are Disallowed if performed on the same date of service as a palliative treatment by the same Dentist/dental office.
10. A Routine cleaning is included in a full mouth debridement and a periodontal maintenance cleaning. As a result, each of these procedures is counted toward your cleaning benefit of once in a six (6) month period.
11. A cleaning done on the same date by the same Dentist/dental office as a periodontal maintenance, or scaling and root planing is considered to be part of and included in those procedures. The fee is Disallowed.
12. Fees for periodontal maintenance are Disallowed when billed within three (3) months of periodontal therapy by the same Dentist/dental office.
13. Periodontal scaling and root planing is a covered benefit per quadrant once in a period of twenty-four (24) months. Benefits are paid for a maximum of two (2) quadrants per office visit. Fees are Disallowed for twenty-four (24) months after the initial therapy if the retreatment is performed by the same Dentist/dental office. If treatment is done by a different Dentist within twenty-four (24) months, benefits are Denied. The patient is responsible for the fee.
14. A partial pulpotomy is a covered benefit, once per tooth per lifetime, on permanent teeth only. The fee for a partial pulpotomy is Disallowed if performed within forty-five (45) days on the same tooth by the same Dentist/dental office as root canal therapy.
15. Pulpal therapy is a covered benefit once in a three (3) year period on primary and secondary molars only. If pupal therapy is performed on primary anterior or permanent teeth, the procedure will be covered as palliative treatment.
16. Therapeutic pulpotomy is a covered benefit once in a three (3) year period per tooth on primary teeth only. If the service is provided on permanent teeth, the procedures will be covered as palliative treatment.
17. Pulpal debridement is a covered benefit once in a lifetime. The fee for pulpal debridement is Disallowed if performed within thirty (30) days of a root canal treatment by the same Dentist/dental office.
18. Routine post-operative visits are considered part of, and included in the fee for, the total procedure. A Participating Dentist agrees not to charge a separate fee.
19. Pin retention is a covered benefit once per tooth in a period of twenty-four (24) months in conjunction with all restorations. Fees for additional pins in the same tooth are Disallowed. The fee for pin retention is Disallowed when billed in conjunction with a core buildup.
20. Post-operative treatment of complications from oral surgery is a covered benefit once per surgical site, subject to a dental consultant’s review. The fee for post-operative treatment of complications is Disallowed if performed within thirty (30) days by the same Dentist/dental office as the oral surgery.
21. The fee for removal of residual tooth roots is Disallowed when performed on the same date of service as an extraction by the same Dentist/dental office.
22. Alveoplasty is included in the fee for surgical extractions. Separate fees for these procedures are Disallowed if performed by the same Dentist/dental office in the same surgical area on the same date.
23. A frenulectomy or frenuloplasty is a covered benefit once per site per lifetime. The fee is Disallowed when billed on the same date as any other surgical procedure in the same surgical area by the same Dentist/dental office.
24. Reattachment of a tooth fragment, including incisal edge or cusp, is a covered benefit. Payment is Disallowed if performed within twenty-four (24) months of a restoration on the same tooth by the same Dentist/dental office.
25. An internal root repair is a covered benefit once in a lifetime on permanent teeth only. If performed on a primary tooth the benefit is Denied. The fee for an internal root repair is Disallowed if performed on the same date of service by the same Dentist/dental office as an apicoectomy or retrograde filling.
26. A consultation performed by a Dentist who is not performing further services is a covered benefit. The fee for a consultation is Disallowed if performed in conjunction with an oral evaluation by the same Dentist/dental office on the same date of service.
27. Exploratory surgical services are not a covered benefit. The patient is financially responsible.
28. General anesthesia is a benefit only when administered by a properly licensed Dentist in a dental office with covered oral surgical procedures or when necessary due to concurrent medical conditions. Otherwise, the fee for general anesthesia is Xxxxxx.
29. The fee for repairs of complete or partial dentures cannot exceed half the fee for a new appliance. Any excess fee billed by the same Dentist/dental office on the same date of service is Disallowed.
30. Fees for adjustments or repairs of complete or partial dentures, if performed within six (6) months of initial placement by the same Dentist/dental office, are Disallowed
31. Adjustment or repair of a denture is a covered benefit twice in a twelve (12) month period. Fees for an adjustment or repair of a denture are Disallowed if performed within six (6) months of initial placement. The fee for an adjustment or repair of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
32. The relining of a denture is a covered benefit two (2) times in a period of twelve (12) months. The fee for reline of a denture cannot exceed one-half of the fees for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
33. The rebase of a denture is a covered benefit once in three (3) years. The fee for rebase of a denture cannot exceed one-half of the fee for a new appliance. Any excess fee by the same Dentist/dental office on the same date of service is Disallowed.
34. The fee for a reline or rebase of a denture is Disallowed if performed within six (6) months of initial placement by the same Dentist/dental office.
35. Rebase and reline include adjustments required within six (6) months of delivery. When an adjustment is billed within six (6) months of a rebase or reline by the same Dentist/dental office, fees for the adjustment are Disallowed.
36. Recementation of a fixed partial denture is a covered benefit once in a period of twelve (12) months. Fees for recementation of fixed partial dentures are Disallowed if done within six (6) months of the initial placement by the same Dentist/dental office.
37. Cleaning and inspection of a removable complete or partial denture is not a covered benefit. The fee for cleaning and inspection of a removable complete or partial denture is Disallowed when done by the same Dentist/dental office on the same date of service as a reline or rebase of the denture. Otherwise, the fee for cleaning and inspection of a removable or complete or partial denture is Disallowed.
38. Bone replacement graft for ridge preservation is a covered benefit once per site per lifetime.
39. Recementation of a prefabricated post and core is a covered benefit once per tooth per lifetime. Payment is Disallowed if performed within six (6) months of the initial placement by the same Dentist/dental office, or if performed on the same date of service of a crown recementation by the same Dentist/dental office.
40. Tissue conditioning is a covered benefit two (2) times in a three (3) year period. The fee for tissue conditioning is not a benefit if performed on the same day the denture is delivered or a reline/rebase is provided by the same Dentist/dental office and is Disallowed.
41. Tooth preparation, bases, copings, protective restorations, impressions, and local anesthesia, or other services that are part of the complete dental procedure, are considered components of, and included in the fee for, a complete procedure. Separate fees are Disallowed.
42. Therapeutic drug injections are a covered benefit subject to a dental consultant’s review.
43. Local anesthesia in conjunction with any procedure by the same Dentist/dental office is considered part of the overall procedure. Separate fees are Disallowed.
44. Excision of lesions is not a covered benefit. The patient is financially responsible. 45. Interim caries arresting medicament application is not a covered benefit.
Appears in 1 contract
Samples: Member Benefit Agreement
