Common use of Precertification Clause in Contracts

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. 🞈 🞈 Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fillings 🞈 Simple extractions, Removal of impacted teeth, General anesthesia 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Covered Covered 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. 🞈 � � Oral evaluations, x-rays, Cleaning s Sealants and fluoride, Space maintainers  🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings ) 🞈 Sedative fillin gs 🞈 Simple extractions, Removal of impacted teeth, General anesthe sia 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp cap ping 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue g rafts 🞈 Crowns, Removable complete and partial de ntures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Covered  Covered 🞈 🞈 Examinat ions, Records Tooth guidance, Repositioning (straightening) of the teeth • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. We will not provide This summary of benefits for serviceshas been updated to comply with federal and state requirements, supplies or charges for any pre-existing condition for including applicable provisions of the time period specified below (subject to HIPAA portability requirements recently enacted federal health care reform laws. As we receive additional guidance and excludes members under age 19): A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending clarification on the member’s enrollment datenew health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. Pregnancy Individual/Family Combined In and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence Out of a diagnosis. Network Out of Network Reimbursement 90th percentile 🞈 🞈 Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fillings 🞈 Simple extractions, Removal of impacted teeth, General anesthesia 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue g🞈 🞈 🞈 rafts 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair �Missing Teeth � Implants NCovered ot Covered Not Covered 🞈 Missing Teeth Covered Covered 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.