Please note that the Group Guidelines amends the Standard Processing Guidelines
Covered Dental Services |
Limitations |
Your dental care program covers the following services when performed by a licensed dentist, certified denturist or registered hygienist to the extent that he or she is operating within the scope of his or her license, certificate or registration as required under law in the State of practice; and when determined to be necessary and customary by the standards of generally accepted dental practice for the prevention or treatment of oral disease or for accidental injury, including masticatory function. Such standards shall be determined by a panel of dentists and approved by the Moda Health Board of Directors.
Covered dental services are outlined in 3 "classes" that start with preventive care and advance into specialized dental procedures. Limitations may apply to these services.
Routine examination and x-rays to assist in determining required dental treatment.
Prophylaxis (cleaning).
Topical application of fluoride.
Space maintainers.
Sealants.
Provides amalgam fillings on posterior (back) teeth and composite fillings on anterior (front) teeth for the treatment of carious lesions (decay).
Surgical extractions, other minor surgical procedures, general anesthesia or IV sedation when administered by a dentist in connection with a covered oral surgical procedure performed in a dental office.
Procedures for pulpal therapy and root canal filling.
Surgical and non-surgical procedures for treatment of the tissues supporting the teeth.
Cast restorations necessary to restore carious lesions (decayed) or broken teeth to a state of functional acceptability.
Bridges, partials, and complete dentures. Includes denture relines and repair of an existing prosthetic device.
GENERAL LIMITATION - OPTIONAL SERVICES
If an eligible person selects a more expensive plan of treatment than is functionally adequate, Moda Health will pay the applicable percentage of the maximum plan allowance for the least costly treatment. The patient will then be responsible for the remainder of the dental provider's fee.
1. Routine examination is covered only once in any six (6) month period. Separate charges for review of a proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not covered.
2. Complete mouth x-rays or a panoramic film is covered only once in any three (3) year period, and supplementary bitewing x-rays are covered only once in any six (6) month period.
1. Prophylaxis (cleaning) or periodontal maintenance is covered only once in any six (6) month period.
2. Topical application of fluoride is covered only once in any six (6) month period for all ages.
3. Sealant benefits are limited to the unrestored occlusal surfaces of permanent bicuspids and molars. Benefits will be limited to one sealant, per tooth, during any five (5) year period.
1. Composite, resin, or similar restorations in posterior (back) teeth are considered optional services. Coverage shall be made for a corresponding amalgam restoration.
2. Refer to Class III Limitations for further limitation when teeth are restored with crowns or cast restorations.
3. A separate charge for general anesthesia and/or IV sedation when used for non-surgical procedures is not covered.
1. A separate, additional charge for alveoloplasty done in conjunction with removal of teeth is not covered.
2. General anesthesia and/or IV sedation except when administered by a dentist in conjunction with covered oral surgery in his or her office.
1. A separate charge for cultures is not covered.
2. Pulp capping is covered only when there is exposure of the pulp.
1. A separate charge for periodontal charting is not covered.
2. Periodontal scaling and root planing is limited to once per quadrant in any twenty-four (24) month period.
3. Coverage for periodontal maintenance procedure or prophylaxis (cleaning) is limited to once in any six (6) month period.
4. A separate charge for post-operative care done within six (6) months following periodontal surgery is not covered.
1. Cast restorations (including pontics) are covered once in a five (5) year period on any tooth.
2. Porcelain restorations are considered cosmetic dentistry if placed on the upper second or third molars or the lower first, second or third molars. Coverage is limited to gold without porcelain.
3. If a tooth can be restored with a material such as amalgam, but another type of restoration is selected by the patient and dentist, covered expense will be limited to the cost of amalgam.
1. A replacement prosthetic device will be covered only once in a five (5) year period. In addition, if it is a replacement of an existing device, the existing device must be unserviceable and unable to be made serviceable.
2. Full, immediate and overdentures: If personalized or specialized techniques are used, the covered amount will be limited to the cost for a standard full denture. Interim (temporary) complete dentures are not covered.
3. Partial dentures: If a specialized or precision device is used, covered expense will be limited to the cost of a standard cast partial denture.
4. Denture adjustments and relines: A separate, additional charge for denture adjustments and relines done within six (6) months after the initial placement is not covered. Subsequent relines will be covered only once in a twelve (12) month period.
5. No payment is provided for cast restorations for partial denture abutment teeth unless the tooth requires a cast restoration due to carious lesions (decay) or broken teeth.
6. Surgical placement, removal of implants, or related services are not covered. Based on Professional review, we may benefit:
a. The final crown and abutment over a single implant. This benefit is limited to once per tooth in any five-year period; or
b. Provide an alternate benefit per arch of a full or partial denture when the implant is placed to support a prosthetic device. The alternate benefit will apply to the frequency limitation (only once in any five-year period) for prosthetic devices.
7. Fixed bridges or removable cast partials are not covered for patients under age sixteen (16).
8. Porcelain prosthetics to replace posterior (back) teeth are considered optional. Coverage shall be made for a corresponding metallic prosthetic.
The following are not covered:
· Services for injuries or conditions which are compensable under workers' compensation or employer's liability laws;
· Services which are provided by any city, county, state or federal law, except for Medicaid coverage; or
· Services which are provided, without cost to the eligible person, by any municipality, county or other political subdivision or community agency, except to the extent that such payments are insufficient to pay for the applicable covered dental services provided under this Policy.
1. Procedures, appliances, restorations or other services that are primarily for cosmetic purposes are excluded.
2. Services or supplies caused by or provided to correct congenital or developmental malformations; including, but not limited to cleft palate, maxillary and/or mandibular (upper and lower jaw) malformations, enamel hypoplasia, and fluorosis (discoloration of teeth), are excluded.
3. Services or supplies for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth are excluded. Such services include, but are not limited to, increasing vertical dimension, equilibration, periodontal splinting, and nightguards.
4. Services or supplies for treatment of any disturbance of the temporomandibular joint are excluded.
5. Gnathologic recordings or similar procedures are excluded.
6. Dental services started prior to the date the individual became eligible for such services under the Policy are excluded.
7. Hypnosis, premedications, analgesics, anesthetics, or any other prescribed drugs are excluded.
8. Hospital charges for services or supplies or additional fees charged by the dental provider for hospital treatment are excluded.
9. Charges for missed or broken appointments are excluded.
10. Experimental procedures or supplies are excluded.
11. Orthodontic services (treatment of malalignment of teeth and/or jaws) are excluded.
12. This Plan does not cover services rendered or supplies furnished after the date the patient ceases to be eligible hereunder, except for Class III services which were ordered and fitted prior to such date and then only if such items are placed within thirty-one (31) days after such termination of eligibility.
13. This Plan does not cover general anesthesia and/or IV sedation except when administered by a dentist in conjunction with covered oral surgery in his or her office.
14. Surgical placement or removal of implants or attachments to implants. See Limitations.
15. Plaque control and oral hygiene or dietary instruction are not covered.
16. Any condition, disease, ailment, injury or diagnostic service to the extent that benefits are provided or would have been provided had the patient enrolled, applied or maintained eligibility for such benefits under Title XVIII of the Social Security Act, including amendments thereto, are excluded.
17. Claims submitted more than 15 months after the date of rendition of the service are not covered.
18. Exclusions include all other services or supplies not specifically included in this Policy as covered dental services.
19. Taxes.