PEDIATRIC DENTAL SERVICES Clause Samples
The Pediatric Dental Services clause defines the coverage, terms, and limitations related to dental care for children under a health or dental insurance plan. It typically outlines which pediatric dental procedures are included, such as routine check-ups, cleanings, fluoride treatments, and sometimes orthodontic care, as well as any age restrictions or cost-sharing requirements. By specifying these details, the clause ensures that families understand what dental services are available for their children and helps prevent disputes over coverage, thereby promoting access to essential oral health care for minors.
PEDIATRIC DENTAL SERVICES. 2.1 Subject to the terms and conditions of the Agreement, benefits will be provided for the following Covered Dental Services when rendered and billed for by a Dentist as specified in the attached Schedules of Benefits.
2.2 Pediatric dental benefits for Members up to the end of the calendar year in which the Member turns age 19 will be provided in accordance with the High Option dental benefits of the Federal Employees Dental and Vision Insurance Program (FEDVIP) as specified in the Schedule of Benefits.
2.3 Class I - Preventive and Diagnostic Services
A. Services limited to twice per Benefit Period.
1. Oral examination including oral health risk assessment
2. Routine cleaning of teeth (dental prophylaxis)
3. Topical application of fluoride
4. Bitewing x-ray (not taken on the same date as those in B. below)
5. Pulp vitality tests; additional tests may be allowed for accidental injury and trauma, or other emergency
B. Services limited to one per 60 months SAMPLE
1. Intraoral complete series x-ray (full mouth x-ray including bitewings)
2. One panoramic x-ray and one additional set of bitewing x-rays
C. Services limited to once per tooth per 36 months: sealants on permanent molars
D. Space maintainers when Medically Necessary due to the premature loss of a posterior primary tooth
E. Services as required
1. Palliative Treatments once per date of service
2. Emergency Oral Exam once per date of service
3. Periapical and occlusal x-rays limited to the site of injury or infection
4. Professional consultation rendered by a Dentist, limited to one consultation per condition per Dentist other than the treating Dentist
5. Intraoral occlusal x-ray
6. One cephalometric x-ray
2.4 Class II - Basic Services
A. Direct placement fillings limited to:
1. Silver amalgam, resin-based composite, compomer, glass-ionomer or equivalent material accepted by the American Dental Association and/or the United States Food and Drug Administration
2. Direct pulp caps and indirect pulp caps
B. Non-Surgical periodontic services limited to:
1. Periodontal scaling and root planning once per 24 months per quadrant
2. Full mouth debridement to enable comprehensive periodontal procedure one per lifetime
3. Periodontal maintenance procedures four per 12 months
PEDIATRIC DENTAL SERVICES. Benefits are provided for Members for the following when rendered by a Dentist who is a Network Provider:
a. Oral Evaluations:
i) Comprehensive, periodic and limited problem focused - one (1) of these services per six (6) months. Once paid, comprehensive evaluations are not eligible to the same office unless there is a significant change in health condition or the patient is absent from the office for three (3) or more year(s).
ii) Consultations - one (1) of these services per Dentist per patient per twelve (12) months for a consultant other than a pedodontist or orthodontist.
iii) Detailed problem focused - one (1) per Dentist per patient per twelve (12) months per eligible diagnosis.
b. Radiographs - Full mouth x-rays - one (1) every five (5) year(s). Bitewing x-rays - one (1) set per six (6) months.
c. Prophylaxis - one (1) per six (6) months. One (1) additional for Members under the care of a medical professional during pregnancy.
PEDIATRIC DENTAL SERVICES. A. Limitations
1. Covered Dental Services must be performed by or under the supervision of a Dentist with an active and unrestricted license, within the scope of practice for which licensure or certification has been obtained.
2. Benefits will be limited to standard procedures and will not be provided for personalized restorations or specialized techniques in the construction of dentures including precision attachments and custom denture teeth.
3. If a Member switches from one Dentist to another during a course of treatment, or if more than one Dentist renders services for one dental procedure, CareFirst shall pay as if only one Dentist rendered the service.
4. CareFirst will reimburse only after all dental procedures for the condition being treated have been completed (this provision does not apply to orthodontic services).
5. In the event there are alternative dental procedures that meet generally accepted standards of professional dental care for a Member’s condition, benefits will be based upon the lowest cost alternative procedure.
B. Exclusions Benefits will not be provided for:
1. Replacement of a denture or crown as a result of loss or theft.
2. Replacement of an existing denture or crown that is determined by CareFirst to be satisfactory or repairable.
3. Replacement of dentures, implants, metal and/or porcelain crowns, inlays, onlays, pontics and crown build-ups within 60 months from the date of placement or replacement for which benefits were paid in whole or in part under the terms of this Description of Covered Services and are judged by CareFirst to be adequate and functional.
4. Gold foil fillings.