COMMUNITY SERVICES. DENTISTS MANUAL Employment Support & Income Assistance (ESIA) Administered by Green Shield Canada (GSC)
|
|
- Cornelia Phillips
- 6 years ago
- Views:
Transcription
1 COMMUNITY SERVICES DENTISTS MANUAL Employment Support & Income Assistance (ESIA) Administered by Green Shield Canada (GSC)
2 EMPLOYMENT SUPPORT & INCOME ASSISTANCE (ESIA) DENTAL SERVICES The Nova Scotia Department of Community Services (DCS) has created a list of dental procedures that will be covered for eligible recipients of the Employment Support & Income Assistance (ESIA) Program. Procedures will be paid at fees established by the DCS. Procedures are for emergencies only where a condition(s) require immediate attention. The program is not intended to provide comprehensive or preventative basic dental care. ESIA DENTAL SERVICES ELIGIBILITY Coverage may be provided under the following condition(s): 1. for the relief of pain; 2. for control of prolonged bleeding; 3. for treatment of swollen tissue; 4. for provision or repair of broken dentures; and/or 5. for dental problems identified as barriers to employment Only the most cost effective treatment plan meeting the above noted condition(s) will be covered. GUIDELINES 1. Only the procedures and applicable fees listed in the ESIA Dental Rates Schedule will be covered unless prior approval has been provided by Green Shield Canada (GSC). 2. Specialist fees for certain procedures are not covered. For these procedures, GSC will reimburse specialists at the general practitioners rate only. If no specialist fee is listed in the ESIA Dental Rates Schedule, the general practitioners rates apply. 3. Fees for certain procedures may be restricted by number, time units, or other criteria. 4. Payment will not be made by GSC for an approved dental procedure claim received more than six months from the date of the completion of treatment. 5. Approval must be received before treatment commences. Payment will not be made by GSC for treatments started before an approval is received. Claims for treatment procedures requiring multiple appointments must be submitted the day the final treatment is complete and not before. In the case of prosthodontic procedures, this would be the date of insertion. 6. Children who are covered by the MSI Children s Oral Health Program are not eligible for coverage under the ESIA Dental Plan. 7. Private dental plan coverage must be billed first. The ESIA Dental Plan will cover any remaining unpaid balance as long as: a) The total payment does not exceed 100% of the 2014 Nova Scotia Dental Association fee guide, AND b) The portion of the payment from the ESIA Dental Plan does not exceed the fee listed in this Manual (which represents 80% of the 2014 Nova Scotia Dental Association fee guide). Green Shield Canada 1 ESIA Dental Services July 2016
3 8. When termination of eligibility occurs and appointments remain to complete a procedure already started, treatment must be completed within 30 days from the date of termination of coverage. Supporting Documentation 9. GSC may request radiographs or study models to assist in the assessment of pre-authorization of procedures, and for the approval of claims. Procedure Limitations 10. A panoramic radiograph is payable only if rendered by an Oral Surgeon. Only one panoramic radiograph will be covered per five-year period. Panoramic radiographs are not payable if they are taken for orthodontic reasons. 11. No payment shall be made for the same dental procedure provided on the same tooth, same surface, within a 180-day period. 12. Scaling is limited to four fifteen-minute units of time per 12-month period and must be provided as a service to relieve pain, control bleeding, or treat swollen tissue. Coverage for scaling is not provided as a preventive benefit. Any additional scaling units required beyond four in a 12-month period must be pre-approved. 13. Root canal therapy is covered for anterior (front) teeth only and must be pre-approved. 14. Tissue conditioning is limited to two procedures per arch in conjunction with new dentures, relines or rebases. If dentures have been done, tissue conditioning can only be provided prior to the insertion of standard dentures and three months after the insertion of immediate dentures. 15. Surgical consultations are payable only with referral from a Medical Doctor or General Dentist. 16. Alveoloplasty is not payable if it is performed in conjunction with an extraction(s) on the same day. 17. ESIA clients may be eligible for assistance to cover the cost of dentures. Pre-approval by GSC is required. Denturists must be licensed in the province of Nova Scotia. Dentures 18. Only one complete or partial denture is covered per arch every five years. 19. Denture relines or rebases will not be covered within 6 months of the date of insertion of a new denture. Green Shield Canada 2 ESIA Dental Services July 2016
4 ADMINISRATION & REIMBURSEMENT 1. Administered by GSC 2. Providers can contact GSC Contact Center ( ) or submit an estimate for confirmation of eligibility before commencing treatment. Confirmation of eligibility requires: Patient s name Patient s health card number Confirmation of approval requires: Patient s name Patient s health card number Provider s unique ID number Procedure code(s) & Fee(s) Date(s) of Service Other relevant information required for treatment on standard dental claim form(s) 3. A claim requires: Any standard dental claim form Approved procedure(s) with relevant information Indication on the form the claim is for an ESIA client Provider s signature Date treatment began, Date treatment completed 4. Submit claims to GSC electronically, via Provider Connect or mail. Electronically (ASYNC or ITRANS): Policy/Plan ID: BIN: More Info: Contact inquiries/approvals/billing below. By Mail: Green Shield Canada ATTENTION: Dental Department P.O. Box 1671 Windsor, ON., N9A 0C6 Provider Connect Portal: Green Shield Canada 3 ESIA Dental Services July 2016
5 Note: The most efficient form of reimbursement is through Electronic Funds Transfer (EFT) and payment is made biweekly. Registration or changes to banking information should be done via Provider Connect secure services. Payments made by cheque are monthly. Green Shield Canada 4 ESIA Dental Services July 2016
6 ESIA DENTAL RATES SCHEDULE Fees listed represent 80% of the 2014 Nova Scotia Dental Association fee guide. CODE DESCRIPTION FEE (GP) FEE (SPEC) DIAGNOSTIC EXAMINATION EMERGENCY ORAL $37.60 $48.80 RADIOGRAPHS RADIOGRAPH SINGLE FILM $12.00 $ RADIOGRAPH TWO FILMS $16.00 $ OCCLUSAL RADIOGRAPH SINGLE FILM $22.40 $29.60 SCALING SCALING - ONE UNIT $31.20 $ SCALING - TWO UNITS $62.40 $ SCALING - THREE UNITS $93.60 $ SCALING - FOUR UNITS $ $ SCALING - HALF UNIT $16.00 $34.40 CARIES/TRAUMA/PAIN CONTROL FIRST TOOTH $71.20 $ EACH ADDITIONAL TOOTH, SAME QUADRANT $71.20 $76.00 SMOOTH OF FRACTURED SURFACES FIRST TOOTH $29.60 $ EACH ADDITIONAL TOOTH, SAME QUADRANT $29.60 $33.60 Green Shield Canada 5 ESIA Dental Services July 2016
7 AMALGAM RESTORATIONS (NON-BONDED TECHNIQUE) PERMANENT ANTERIORS AND PREMOLARS ONE SURFACE $75.20 $ TWO SURFACES $98.40 $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES OR MAXIMUM PER TOOTH $ $ PERMANENT MOLARS ONE SURFACE $87.20 $ TWO SURFACES $ $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES OR MAXIMUM PER TOOTH $ $ AMALGAM RESTORATIONS (BONDED TECHNIQUE) Paid at rate of non-bonded amalgam restorations PERMANENT ANTERIORS AND PREMOLARS ONE SURFACE $75.20 $ TWO SURFACES $98.40 $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES $ $ PERMANENT MOLARS ONE SURFACE $87.20 $ TWO SURFACES $ $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES $ $ RETENTIVE PINS ONE PIN $17.60 $ TWO PINS $27.20 $ THREE PINS $37.60 $ FOUR PINS $47.20 $ FIVE PINS $56.80 $97.60 Green Shield Canada 6 ESIA Dental Services July 2016
8 TOOTH-COLOURED RESTORATIONS PERMANENT ANTERIORS ONE SURFACE $88.80 $ TWO SURFACES $ $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES OR MAXIMUM PER TOOTH $ $ PERMANENT PREMOLARS ONE SURFACE $ $ TWO SURFACES $ $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES OR MAXIMUM PER TOOTH $ $ TOOTH-COLOURED RESTORATIONS PERMANENT MOLARS Paid at rate of non-bonded amalgam restorations ONE SURFACE $87.20 $ TWO SURFACES $ $ THREE SURFACES $ $ FOUR SURFACES $ $ FIVE SURFACES $ $ ANTERIOR TEETH ONLY WITH COMPOSITE CORE $ materials, + PINS, WHERE APPLICABLE where applicable ENDODONTICS ANTERIORS AND PREMOLARS (EXCL. FINAL RESTORATION) PULPOTOMY-PERMANENT $80.00 $ ROOT CANALS PERMANENT ANTERIORS ONE CANAL $ $ PROSTHODONTICS - REMOVABLE COMPLETE DENTURES (STANDARD) MAXILLARY $ lab fee MANDIBULAR lab fee Green Shield Canada 7 ESIA Dental Services July 2016
9 DENTURES, SURGICAL, STANDARD (IMMEDIATE) MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURES, PARTIAL, ACRYLIC BASE (IMMEDIATE) MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURES RELINES AND REBASES Only one reline or rebase will be covered per arch per two-year period. Relines and rebases are not covered within 6 months of the date of insertion of a new denture. DENTURE, RELINE, DIRECT, COMPLETE DENTURE MAXILLARY $ MANDIBULAR $ DENTURE, RELINE, DIRECT, PARTIAL DENTURE MAXILLARY $ MANDIBULAR $ DENTURE, RELINE, PROCESSED, COMPLETE DENTURE MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURE, RELINE, PROCESSED, PARTIAL DENTURE MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURE, REBASE, COMPLETE DENTURE MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURE, REBASE, PARTIAL DENTURE MAXILLARY $ lab fee MANDIBULAR $ lab fee Green Shield Canada 8 ESIA Dental Services July 2016
10 DENTURES, REPAIRS (THREE MONTHS AFTER INSERTION) REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIRED MAXILLARY $ lab fee MANDIBULAR $ lab fee REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED MAXILLARY $ lab fee MANDIBULAR $ lab fee REPAIRS, PARTIAL DENTURE, NO IMPRESSION REQUIRED MAXILLARY $ lab fee MANDIBULAR $ lab fee REPAIRS, PARTIAL DENTURE, IMPRESSION REQUIRED MAXILLARY $ lab fee MANDIBULAR $ lab fee DENTURES, THERAPUTIC TISSUE CONDITIONING Tissue conditioning is limited to two procedures per arch in conjunction with new dentures, relines or rebases. If dentures have been done, tissue conditioning can only be provided prior to the insertion of standard dentures and after three months after the insertion of immediate dentures. COMPLETE DENTURE MAXILLARY $ MANDIBULAR $ PARTIAL DENTURE MAXILLARY $ MANDIBULAR $ Green Shield Canada 9 ESIA Dental Services July 2016
11 ORAL SURGERY SURGICAL CONSULTATION Payable only with referral from Medical Doctor or General Dentist SURGICAL CONSULTATION $82.40 PANORAMIC RADIOGRAPH Payable only if rendered by an Oral Surgeon. Limited to one film per five-year period. Not payable for orthodontic reasons SINGLE FILM $62.40 SURGICAL REMOVAL OF ERUPTED TEETH SINGLE TOOTH UNCOMPLICATED $90.40 $ EACH ADDITIONAL, SAME QUAD, SAME APPT. $60.80 $ COMPLICATED REQUIRING SURGICAL FLAP $ $ EACH ADDITIONAL, SAME QUAD, SAME APPT. $ $ REMOVALS, (EXTRACTIONS), IMPACTED TEETH Payable only as part of a prior-approved treatment plan SINGLE TOOTH $ $ EACH ADDITIONAL TOOTH, SAME QUADRANT $ $ REMOVAL, RESIDUAL ROOTS, ERUPTED FIRST TOOTH $70.40 $ EACH ADDITIONAL TOOTH, SAME QUADRANT $47.20 $85.60 REMOVAL, RESIDUAL ROOTS, SOFT TISSUE COVERAGE FIRST TOOTH $ $ EACH ADDITIONAL TOOTH, SAME QUADRANT $85.60 $ REMOVAL, RESIDUAL ROOTS, BONE TISSUE COVERAGE FIRST TOOTH $ $ EACH ADDITIONAL TOOTH, SAME QUADRANT $ $ Green Shield Canada 10 ESIA Dental Services July 2016
12 ALVEOLOPLASTY Payable only as part of a prior-approved treatment plan. Not payable if performed in conjunction with extraction on same day PER SEXTANT $ $ GINGIVOPLASTY PER SEXTANT $67.20 $ SEDATION Payable only as part of a prior-approved treatment plan ONE UNIT OF TIME $60.80 $ TWO UNITS OF TIME $ $ Green Shield Canada 11 ESIA Dental Services July 2016
Where a restoration is provided, no payment will be made for stainless steel crown or prefabricated plastic crown for thirty (30) days.
CHILD DENTAL BENEFITS Effective July 1, 2017 to June 30, 2019 Child dental coverage is provided to dependant children of Alberta Adult Health Benefit (AAHB) and Income Support receipients (Expected to
More informationThe following services may be provided:
CHILD HEALTH BENEFIT DENTAL COVERAGE Effective July 1, 2017 to June 30, 2019 Child Health Benefit (CHB) dental coverage is provided to dependant children enrolled in the Alberta Child Health Benefit (ACHB)
More informationYork Region Ontario Works Adult Dental Program Handbook
York Region Ontario Works Adult Dental Program Handbook November 2017 Introduction This handbook has been written for dental practitioners and outlines the policy and procedures for York Region Community
More informationDentists. Schedule of Dental Services and Fees for Ontario Works Adults
Dentists Schedule of Dental Services and Fees for Ontario Works Adults 2017 2017 Ontario Works Adults - Schedule of Dental Services and Fees PURPOSE OF THE PROGRAM Halton Region does not intend to provide
More informationAnthem Blue Dental PPO Voluntary Option 2V Summary of Benefits
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual
More informationGUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual
Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00
More informationSCHEDULE B 4.0 PERIODONTICS Specialty Procedure Code Fee Type of change GP $51.03 Modified Perio $60.61 Modified Perio $41.
July 15, 2015 Communication to all NIHB Discrepancies were recently found in the Quebec NIHB Regional Dental Benefit Grids (effective May 1, 2015 - Revised June 1, 2015 v 2.0). The changes listed below
More informationCommunication to all NIHB General Practitioners & Specialists in Ontario
October 1, 2018 Communication to all NIHB General Practitioners & Specialists in Ontario Effective October 1, 2018, the fees for the following NIHB Orthodontic Unique Procedure Codes have been changed
More informationNEW BRUNSWICK NIHB Regional Dental Benefit Grid General Practitioners and Specialists
Effective Date March 1, 2017 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Schedule B Procedures require
More informationDental Supplement. Denturist. Ministry of Social Development and Poverty Reduction
Dental Supplement Denturist Ministry of Social Development and Poverty Reduction TABLE OF CONTENTS Part A - Preamble - Dental Supplements - Denturist pages i - v The Preamble - Dental Supplements - Denturist
More informationPRINCE EDWARD ISLAND NIHB Regional Dental Benefit Grid General Practitioners and Specialists
Effective Date March 1, 2017 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Schedule B Procedures require
More informationQUEBEC NIHB Regional Dental Benefit Grid General Practitioners and Specialists
Effective Date May 1, 2017 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Schedule B Procedures require
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All
More informationCommunication to all NIHB General Practitioners & Specialists in the Northwest Territories
November 9, 2018 Communication to all NIHB General Practitioners & Specialists in the Northwest Territories Effective December 5, 2018, clients 17 years of age and older will be eligible for fluoride treatments,
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:
More informationCommunication to all NIHB General Practitioners and Specialists
June 1, 2015 Communication to all NIHB Discrepancies were recently found in the Ontario NIHB Regional Dental Benefit Grids (effective April 1, 2015). The changes listed below have been updated and highlighted
More informationGUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER
OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio
More informationCommunication to all NIHB General Practitioners & Specialists in Alberta
December 17, 2018 Communication to all NIHB General Practitioners & Specialists in Alberta Effective January 1, 2019, in order to reflect CDA s new fluoride treatment code structure, NIHB is introducing
More informationExclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED
More informationNEWFOUNDLAND AND LABRADOR NIHB Regional Dental Benefit Grid General Practitioners and Specialists
Effective Date March 1, 2019 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Schedule B Procedures require
More informationSCHEDULE A 1.0 PREVENTION Specialty Procedure Code Description/ Fee GP, Paed., Perio $12.66
July 19, 2013 Communication to all NIHB Effective August 1, 2013, Procedure Code 11107 will be reinstated as an eligible dental service under the Non-Insured Health Benefits Program. The change listed
More informationManaged DentalGuard Texas
Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131
More informationDelta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page
List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
More informationAPPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
More informationLIST OF COVERED DENTAL SERVICES
LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental Services which will be considered for payment by Constitution Life Insurance Company after the expiration of any applicable
More informationDiagnostic No One of (D0210, D0330) per 36 Month(s) Per patient No No Ten of (D0230) per 1 Day(s) Per patient.
Dental and Authorization Guide Diagnostic services include the oral examinations, and selected radiographs, needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment
More informationAdministered by: The Public Employees Benefits Agency
Public Employees Benef its Agency Public Employees Dental Plan Reimbursement Schedule for Employees of the Out-of-Scope Employees of Executive Government Effective January 1, 2018 Pre-Authorization Where
More informationAetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown
More informationAPPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
More informationAPPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
More informationThe following chart provides an illustration of the dental coverage provided under the Plan. Summary of Dental Care Benefits
DENTAL CARE You or your eligible dependents may incur reasonable and customary charges for services and supplies provided by or under the supervision of a licensed, certified or registered oral surgeon
More informationStaywell FL Child Medicaid Plan Benefits
The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical
More informationThe. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation
The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing
More informationNewport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan
Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications
More informationADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth $ 35.00
Northeast General Dentistry Fee Schedule I District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia Please note: This fee schedule applies to procedures performed by a General Dentists
More informationSECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE
DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed
More informationSenior Dental Insurance Scheduled Allowance
Senior Dental Insurance Scheduled Allowance LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental services which will be considered for payment by The American Progressive Life
More informationFEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:
FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS
More informationAetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits
More informationTeachers' Dental Plan Maximum Reimbursement Levels
Teachers' Superannuation Commission Dentist Payment Schedule Teachers' Dental Plan Maximum Reimbursement Levels January 1, 2019 Teachers' Teachers' Dental Dental Description Code Plan Description Code
More informationDominion Dental Services
Dominion Dental Services Plan 603X Presented by Professional Benefit Administrators 1 (800) 578-2082 SUMMARY OF BENEFITS AND COPAYMENTS Enrollee pays DIAGNOSTIC Office Visit/Infectious Disease Control.....$
More informationDELTA DENTAL PPO EPO PLAN DESIGN CP070
DELTA DENTAL PPO EPO PLAN DESIGN CP070 SCHEDULE OF BENEFITS AND The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations and exclusions of the program.
More informationONTARIO WORKS ADULT. Emergency Denture Services. Denturist Fee Schedule. District of Muskoka
ONTARIO WORKS ADULT Emergency Denture Services Denturist Fee Schedule District of Muskoka May 2012 Maximum Fees Maximum fees and laboratory charges payable by District of Muskoka Ontario Works are as
More information23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are
More informationDenturists. Schedule of Dental Services and Fees for Ontario Works Adults Halton Oral Health Outreach Dental Care Counts
Denturists Schedule of Dental Services and Fees for Ontario Works Adults Halton Oral Health Outreach Dental Care Counts 2017 Denturists 2017 Schedule of Dental Services and Fees Dental Care Counts & Ontario
More informationDelta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments
List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
More informationSummary of Benefits Dental Coverage - New Dental Option
Summary of Benefits Dental Coverage - New Dental Option Managed Dental Plan MET225 - Texas Code Description Co-Payment Diagnostic Treatment D0120 Periodic Oral Evaluation established patient $0 D0150 Comprehensive
More informationDelta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
More informationONTARIO WORKS IN PEEL
ONTARIO WORKS IN PEEL SCHEDULE OF EMERGENCY DENTAL/DENTURE SERVICES and FEES Adult Emergency Discretionary Dental/Denture Plan Revised: March 28, 2017 TABLE OF CONTENTS ADULT EMERGENCY DISCRETIONARY DENTAL
More informationDelta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
More informationONTARIO NIHB Regional Dental Benefit Grid Denturists
Denturists Effective Date April 1, 2019 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Predetermination
More informationGeneral Dentist Fee Schedule
General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient
More informationRETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8
D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation
More informationGeneral Dentist Fee Schedule
General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient
More informationFor a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf
Correction Captains Association Retiree Security Benefit Fund Group #132 Summary of Benefit for Retired members: Annual maximum $3,500.00 individual Individual Ortho Lifetime max $3,500 Appliance $600,
More informationSASKATCHEWAN NIHB Regional Dental Benefit Grid Denturists
Denturists Effective Date February 1, 2019 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Predetermination
More informationADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding (per tooth): D2960 Full face buildup chairside $
New England General Dentistry Fee Schedule Connecticut, Massachusetts, New Hampshire & Rhode Island Please note: This fee schedule applies to procedures performed by a General Dentists only. Rates are
More informationADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS
PRESTIGE 25 Schedule of Benefits and Subscriber Copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS 5130 Immediate maxillary (upper)...$300.00 9430 Office visit (normal
More informationHumanaDental PPO 09 (High Option)
HumanaDental PPO 09 (High Option) FLORIDA ICUBA If you use IN-NETWORK provider If you use OUT-OF-NETWORK provider Plan-year deductible Annual maximum Preventive services Oral examinations X-rays Cleanings
More informationSECTION 8 DENTAL BENEFITS SCHEDULE OF DENTAL BENEFITS
SECTION 8 DENTAL BENEFITS The Fund pays up to a maximum of $2,000 per year for Dental expenses incurred by Participants and/or Dependents age 19 or over in accordance with the Schedule of Dental benefits;
More information02130 Cavities involving three surfaces 10.00
( ) 02130 Cavities involving three surfaces 10.00 AMALGAM RESTORATIONS, PERMANENT TEETH: 02140 Cavities involving one tooth surface $ 5.00 02150 Cavities involving two tooth surfaces 8.00 02160 Cavities
More informationNEWFOUNDLAND AND LABRADOR NIHB Regional Dental Benefit Grid Denturists
Denturists Effective Date March 1, 2018 The coverage of dental services provided through the NIHB Program will be reimbursed in accordance with the terms and conditions of the Program. Predetermination
More informationSERVICES. COMPLETE AND PARTIAL DENTURE SERVICES (STANDARD AND SUPPLEMENTARY BENEFITS) EFFECTIVE July 1, 2017 to June 30, 2018
SCHEDULE A SERVICES COMPLETE AND PARTIAL DENTURE SERVICES (STANDARD AND SUPPLEMENTARY BENEFITS) EFFECTIVE July 1, 2017 to June 30, 2018 GENERAL 1. Members may provide Services to a Client only upon a Client
More informationDental Blue Program 2
SUMMARY OF BENEFITS Dental Blue Program 2 (with Orthodontics) Medium Option Massachusetts Bankers Association Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue
More informationDINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family
DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments
More informationSCHEDULE A Description of Benefits and Copayments DHMO-901
866.650.3660 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-901 The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to
More informationDental Insurance. Eligibility
3.1 Group (Compulsory) Dental Insurance Eligible employees and their families, if applicable, are covered under the Brandon University Dental Plan as presented by the Manitoba Government Employees Association.
More informationAll Participants and Beneficiaries in the Health and Benefit Trust Fund of the International Union
SUMMARY OF MATERIAL MODIFICATIONS TO THE HEALTH AND BENEFIT TRUST FUND OF THE INTERNATIONAL UNION OF OPERATING ENGINEERS LOCAL UNION NO. 94 94A 94B, AFL CIO To: From: All Participants and Beneficiaries
More informationSummary of Benefits - Dental HMO Deluxe Plan
Office visit Office visit $5 per visit Diagnostic (exams and x-rays) D0120 Periodic oral evaluation You pay nothing D0140 Limited oral evaluation - problem focused You pay nothing D0145 Oral evaluation
More informationDental Schedule. Handbook
Your guide to the Alberta Blue Cross Dental Schedule 2017 Dental Schedule Handbook Alberta Blue Cross Dental Schedule: 2017 Helping you keep your healthy smile January 2017 1 2 3 4 5 6 7 8 9 10 11 12 13
More informationDENTAL PLAN QUICK FACTS AND QUICK LINKS
DENTAL PLAN QUICK FACTS AND QUICK LINKS A Quick Look at the Dental Plan Dental Service TakeCare Network Dentists Only Annual Maximum Benefit $1,500 per covered person per calendar year Diagnostic & Preventive
More informationCOVERED SERVICES DIAGNOSTIC AND PREVENTATIVE SERVICES: CO-PAY
PLAN DENTAL 1-2 TIJUANA AV PASEO TIJUANA #406 THIRD FLOOR SIMNSA BUILDING TIJUANA B.C. Tel: (664) 231-4739 Monday Friday: 8 A.M. 8 P.M. Saturday: 8 A.M. 4 P.M. Sunday: 10 A.M. 2 P.M. MEXICALI CALLE E #123
More informationATTACHMENT AA DentaQuest of Illinois, LLC
DentaQuest of Illinois, LLC 112 ATTACHMENT AA DentaQuest of Illinois, LLC HFS Dental Program Fee Schedule for and Adult Beneficiaries Rates Effective July 1, 2009 Please note: have limited dental coverage.
More informationSHL Dental PPO Plan 29 - SB Adult Only Coverage
SHL Dental PPO Plan 29 - SB Adult Only Coverage Attachment A Benefit Schedule Please read the definition of Eligible Dental Expenses ( EDE ) and SHL Reimbursement Schedule in the Certificate. When accessing
More informationScheduled Dental Benefit Plan Schedule of Dental Allowances
Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.00 0140 Limited Oral Evaluation 20.00 0150 Comprehensive Oral
More informationPartial Dentures Acrylic Base - Immediate, w/o clasps Lab Processed with functional impression
December 10, 2010 Communication to all NIHB Denturists Discrepancies were recently found in the Alberta Denturists (effective May 1, 2010). The changes listed below have been updated in the dental benefit
More informationState of Tennessee. Prepaid Plan. Dental Benefit Option. Sponsored by the. State of Tennessee
State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2011 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security
More informationEmployee Benefit Fund July 2018 ADA Codes and Plan Fees
CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48
More informationFlorida Medicaid. Dental Services Coverage Policy. Agency for Health Care Administration
Florida Medicaid Agency for Health Care Administration Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible Recipient... 2 2.1 General
More informationASSISTANT SECRETARY PRESIDENT
Charge Code TYPE I* Benefit Co-Insurance $21.00 0120* Periodic oral exam $21.00 Balance Billing $30.00 0140* Limited oral exam $30.00 Balance Billing $35.00 0150* Comprehensive oral evaluation $35.00 Balance
More informationMassachusetts Family High Dental Plan with Enhanced Child Orthodontia
SCHEDULE OF BENEFITS Massachusetts Family High Dental Plan with Enhanced Child Orthodontia This Schedule of Benefits lists the services available under the MetLife plan, as well as the co-insurance payments
More informationDental Blue Program 2. Summary of Benefits. Amherst College
Dental Blue Program 2 Summary of Benefits Amherst College Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Dental Blue Program 2 Preventive
More informationAetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO
Aetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO PPO Max Annual Deductible* Individual None $75 Family None $225 Preventive Service Covered
More informationWelcome to Arkansas Blue Cross and Blue Shield Dental Plan
Welcome to Arkansas Blue Cross and Blue Shield Dental Plan University of Arkansas System Dental Program Beginning January 1, 2018, the University of Arkansas System dental plan will be administered by
More informationDELTA DENTAL PPO SUMMARY OF BENEFITS FOR COVERED EMPLOYEES OF: County of Dane. (See Dental Benefit Handbook for definitions of capitalized terms.
DELTA DENTAL PPO SUMMARY OF BENEFITS FOR COVERED EMPLOYEES OF: County of Dane (See Dental Benefit Handbook for definitions of capitalized terms.) GROUP NUMBER: 00704-00000 EFFECTIVE DATE OF PROGRAM: January
More informationSECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under age 19 Two (2) or more Members
More informationSECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits
COST-SHARING SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx Member Services:
More informationWASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII
WASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. Forward Your completed claim form
More informationDMO Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 CODE DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic
More informationMEMBER 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
More informationAetna Dental presents A Dental Benefit Summary for Florida Option 3; Freedom-of-Choice; w/ortho DMO
Aetna Dental presents A Dental Benefit Summary for Florida Option 3; Freedom-of-Choice; w/ortho DMO PPO Annual Deductible* Individual None $50 Family None $150 Preventive Service Covered Percent 100% 100%
More informationEssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx
More informationEssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 9 Plantation, FL 33318 Telephone: 877 760 2247 Fax: 954 370 1701 www.mysolstice.net Members can search for a Network Provider atwww.solsticecare.com/provider
More informationUniversity of Arkansas System
University of Arkansas System Dental Plan 2018 Welcome University of Arkansas System employees! Beginning January 1, 2018, the University of Arkansas System (UAS) dental plan will be administered by Arkansas
More information