Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available if the Member: 1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and 2. Has a severe, dysfunctional, handicapping malocclusion that meets a minimum score of 15 on the Handicapping Labio-Lingual Deviations Index (HLD) approved for use by the State of Maryland. Points are not awarded for aesthetics, therefore additional points for handicapping aesthetics will not be considered as part of the determination. B. All orthodontic services require a pre-treatment estimate (PTE) to be submitted to the Dental Plan as described in Section 15.6F, Estimate of Eligible Benefits. The following documentation must be submitted with the PTE: 1. ADA 2006 or newer claim form with service code requested; 2. Diagnostic study models (trimmed) with wax bites or OrthoCAD™ electronic equivalent, 3. Cephalometric head film with measurements and analysis; 4. Panoramic or full series periapical radiographs; 5. Clinical summary with diagnosis; 6. HLD score sheet completed and signed by the orthodontist; and 7. Treatment plan including anticipated duration of active treatment.
Appears in 4 contracts
Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement
Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available if the Member:
1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and
2. Has a severe, dysfunctional, handicapping malocclusion that meets a minimum score of 15 on the Handicapping Labio-Lingual Deviations Index (HLD) approved for use by the State of Maryland. Points are not awarded for aesthetics, therefore additional points for handicapping aesthetics will not be considered as part of the determination.
B. All orthodontic services require a pre-treatment estimate (PTE) to be submitted to the Dental Plan PTE)by CareFirst, as described in Section 15.6F15.3F, Estimate of Eligible Benefits. The following documentation must be submitted with the request for PTE:
1. ADA 2006 or newer claim form with service code requested;
2. Diagnostic study models (trimmed) with wax bites or OrthoCAD™ electronic equivalent,
3. Cephalometric head film with measurements and analysis;
4. Panoramic or full series periapical radiographs;
5. Clinical summary with diagnosis;
6. HLD score sheet completed and signed by the orthodontist; and
7. Treatment plan including anticipated duration of active treatment.
C. Covered benefits if PTE is obtained:
Appears in 2 contracts
Samples: Student Health Plan Individual Enrollment Agreement, Student Health Plan Individual Enrollment Agreement
Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available if the Member:
1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and
2. Has a severe, dysfunctional, handicapping malocclusion that meets a minimum score of 15 on the Handicapping Labio-Lingual Deviations Index (HLD) approved for use by the State of Maryland. Points are not awarded for aesthetics, therefore additional points for handicapping aesthetics will not be considered as part of the determination.
B. All orthodontic services require a pre-treatment estimate (PTE) to be submitted to by the Dental Plan Plan, as described in Section 15.6F15.8E, Estimate of Eligible Benefits. The following documentation must be submitted with the request for PTE:
1. ADA 2006 or newer claim form with service code requested;
2. Diagnostic study models (trimmed) with wax bites or OrthoCAD™ electronic equivalent,
3. Cephalometric head film with measurements and analysis;
4. Panoramic or full series periapical radiographs;
5. Clinical summary with diagnosis;
6. HLD score sheet completed and signed by the orthodontist; and
7. Treatment plan including anticipated duration of active treatment.
C. Covered benefits if PTE is approved:
Appears in 1 contract
