For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf
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1 Correction Captains Association Retiree Security Benefit Fund Group #132 Summary of Benefit for Retired members: Annual maximum $3, individual Individual Ortho Lifetime max $3,500 Appliance $600, active monthly visits $95 for 24 months, $60 monthly for two passive treatments. Retention appliance $500 Pre-Authorizations: Any claims over $ must be pre-authorized. In Network: Providers are reimbursed 100% of either the Sele-Dent fee schedule or Fund fee schedule whichever applies. Out of Network: Providers are reimbursed 100% of the Fund s current out-of- network fee schedule FREQUENCIES: Examination: One every six months. Prophylaxis: One every six months. Full mouth and Panoramic x-rays: One every twelve months. Sealants: No Fluoride: Once every six months, up to age 19. Perio: No Frequency, all four quads same day. Major work: 36 Months replacement on crowns, bridges and dentures. Missing Tooth: Covered Implants covered with mandatory pre-authorization. For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf Always call Sele-Dent, Inc. to verify eligibility, claims status and benefit plan breakdown
2 Correction Captains Out-of-Network dental services schedule DIAGNOSTIC & PREVENTATIVE Oral Examination maximum two in a calendar year $42 Full Mouth Services including bitewings $70 Periapical or Bitewing First Film $10 Panoramic Film $60 Occlusal Film $20 Cephalometric Film $40 Prophylaxis, including scaling and polishing Adult $60 Child to age 12 years maximum two in a calendar year $45 Topical Application of Flouride to age 19 maximum one application in a calendar year $20 Sealant maximum unrestored, permanent teeth only to age 19 $30 Space Maintainer $155 BASIC RESTORATIVE Silver Amalgam Fillings, primary teeth one surface $75 two surfaces $85 three or more surfaces $95 Silver Amalgam Fillings, permanent teeth one surface $75 two surfaces $85 three surfaces $95 four or more surfaces $100 Composite Resin, anterior or posterior teeth one surface $80 two surfaces $90 three or more surfaces $100 four or more surfaces including incisal angle $110 Pin Support, per tooth $30 Metallic or Porcelain Inlay one surface $225 two surfaces $255 three or more surfaces $285 Onlay in addition to Inlay
3 MAJOR RESTORATIVE Crowns, bridges, and removable dentures are limited to once per three years & require per-operative periapical x-ray Crowns Acrylic Jacket (laboratory processed) $350 Porcelain Jacket $500 Plastic with Metal $300 Porcelain with Metal $575 Full Cast $500 Stainless Steel (primary tooth) $75 Porcelain Laminate $300 Post and Core, prefabricated $100 Post and Core, cast $150 Recement Crown $35 Recement Inlay $40 ORAL SURGERY Routine Extraction $75 Surgical Extraction must be demonstrated by submitted x-ray Retained Root $110 Root Removal $115 Impaction Soft Tissue* $150 Impaction Partial Bony* $220 Impaction Complete Bony* $260 Surgical Exposure Impacted or Unerupted Tooth, for Ortho $195 Impacted or Unerupted Tooth, Aid Eruption $115 Alveoloplasty Per Quandrant $150 Incision and Drainage $75 Biopsy $100 *Retirees enrolled in GHI must submit claims for impactions to GHI first, since GHI covers excision of impacted teeth. A copy of the EOB Explanation of Benefits from GHI may then be affixed to a Dental form and submitted to the fund for any additional benefits.
4 PROSTHODONTICS (Crowns, Bridges, and Removable Dentures are limited to once every three years) Complete or Immediate Denture $855 Partial Denture-Bilateral Acrylic Base $425 Cast Metal Base $650 Denture Repairs Broken Denture Base $100 Replace Tooth in Denture $95 Replace Broken Facing $100 Broken Cast Framework $100 Replace Broken Clasp $95 Add tooth to Existing Partial Denture $95 Add Clasp to Existing Partial $95 Denture Adjustment $45 Reline Complete Denture, Chairside $85 Reline Complete Denture, Laboratory $135 Reline Partial Denture, Chairside $60 Reline Partial Denture, Laboratory $110 Tissue Conditioning $50 PROSTHODONTICS (Continued) (Crowns, Bridges, and Removable Dentures are limited to once every three years) Bridge Abutment or Pontic Inlay Two Surface $255 Inlay Two Surface $285 Crown Plastic with Metal $550 Crown Porcelain fused to Metal $600 Crown Full Cast $525 Re-cement Bridge $60 Maryland Bridge Retainer $330 Precision Attachment $135
5 ENDODONTICS (x-ray of satisfactory completion required) Pulp Cap, Direct $20 Pulpotomy $70 Root Therapy One Canal $280 Two Canals $355 Three or More Canals $455 Apicoectomy, First Root $200 Apicoectomy, Maximum Per Tooth $350 Retrograde Filling $110 Hemisection $175 ADJUNCTIVE SERVICES Palliative Treatment Maximum Once in a Calendar Year $45 Specialist Consultation Maximum Once in a Calendar Year, includes Exam $65 General Anesthesia 1 st 30 Minutes Only $225 Intravenous Sedation 1 st 30 Minutes Only $225 Bruxism Appliance $150 PERIODONTICS Although eight teeth constitute the anatomic compliment of a quadrant, for purposes of settling claims for periodontal treatment, payment will be based on five teeth per quadrant. Accordingly, if at least five teeth are treated in a quadrant, payment will be based on the allowance for a full quadrant. If fewer than five teeth are treated, payment will be pro-rated on the basis of five teeth per quadrant. When more than one periodontal procedure is performed on the same day, claims for services will be combined and payment will be based on the most costly procedure. Periodontal Treatment Per Visit Root Scaling & Subgingival Curettage with Prophylaxis $105 Maximum per year $420 Periodontal Surgery Confirmed by charting and/or x-rays required per quadrant of at least five teeth, soft-tissue, gingivectomy or gingivoplasty, mucco-buccal surgery, soft tissue graft or vestibuloplasty. Osseous Graft, Per Quadrant $250 Osseous Graft, Per Site $140 Pedicle Soft Tissue Graft $250 Free Soft Tissue Graft, Per Quadrant $300 Osseous Surgery Including Gingivectomy Maximum One in 36 Months Maximum Per Quad $400
6 ORTHODONTICS Lifetime maximum $3,500 Initial Orthodontic Appliance Full treatment Fixed Appliance $600 Active Treatment Per 24 Months of Treatment $95 Passive Treatment Per 2 Months of Treatment $60 Retention Appliance $500 IMPLANT SERVICES Endosteal Implant $1,200 Subperiosteal Implant $1,200 Prefabricated Abutment $400 Custom Abutment $475 Abutment Supported Crown $675 Implant Supported Crown $975
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DENTAL RATE FEE SCHEDULE rates effective 5/1/15 through 6/30/15
Procedure Code D0120 Description April 2014 Fee Rate cute 16.75% Amount of Reduction May/June 2015 Fee $28.00 $28.00 Periodic Oral Exam Ages 0 thru 18 D0120 Periodic Oral Exam Ages 19 thru 20 and Pregnant
SECURECARE DENTAL COPAY PLAN AZ300 - SCHEDULE OF DENTIST COPAYMENTS
The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services
SECURECARE DENTAL COPAY PLAN NV100 - SCHEDULE OF DENTIST COPAYMENTS
The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services
MEMBER FEE No Charge* No Charge* No Charge*
2019 2019 GENERAL DENTISTRY FEE SCHEDULE Note: This fee schedule applies to procedures performed by a General Dentist only. DIAGNOSTIC & PREVENTIVE PROCEDURES Periodic oral examination Comprehensive oral
Primecare Dental Plan Individual Plan 400B
Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable
SCHEDULE A Description of Benefits and Copayments DHMO-PA3
SCHEDULE A Description of Benefits and s DHMO-PA3 855.280.2882 WWW.PREMIERLIFE.COM The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to the limitations