Florida Healthy Kids Member Handbook May Member Services:

Transcription

1 Florida Healthy Kids Member Handbook May 2017 Member Services:

2 WELCOME TO HEALTHY KIDS What is the Florida Healthy Kids program? DentaQuest partners with Florida Healthy Kids to provide dental plans for children. DentaQuest has a large network of dentists to take care of your child's dental needs. Who is eligible? Your child is eligible for the Florida Healthy Kids program if he or she is: 5 - to 18-years-old Not covered by any other health care plan or insurance Not eligible for Medicaid Identification card Please keep your child's DentaQuest ID card with you at all times. Remember to bring the ID card to all of your child's dental appointments. If the card is lost or if any of the information is incorrect, you may call DentaQuest s member services department toll free at to request a replacement. Informacion del manual del cliente Para obtener esta guia en Espanol, por favor llame al departmento de Servicio al Cliente de DentaQuest. Queremos asegurarnos que usted entiende sus beneficios para poder ayudarlos con cualquier pregunta que tenga. DentaQuest servicio al cliente:

3 TABLE OF CONTENTS DEAR PARENT...5 HOW TO CONTACT US...6 GETTING STARTED...7 CARING FOR YOUR CHILD'S TEETH...10 WHAT ARE MY CHILD'S DENTAL BENEFITS...10 The terms used here can be found in the dental terms appendix. EXCLUSIONS AND LIMITATIONS...12 EMERGENCY DENTAL CARE...14 RENEW YOUR FLORIDA HEALTHY KIDS DENTAL BENEFITS...16 COMPLAINTS, GRIEVANCES AND APPEALS...16 YOU AND YOUR CHILD'S RIGHTS AND RESPONSIBILITIES...19 NOTICE OF PRIVACY PRACTICES...20 DENTAL TERMS...26 Dear Parent... Welcome to DentaQuest! We are proud to partner with the Florida Healthy Kids program to manage dental plans for children. We are pleased your child is enrolled in the Florida Healthy Kids program. Through our large network of general and specialty dentists, your child will receive high quality dental care. This handbook lists the dental benefits available to your child. Please review this handbook so you have a better understanding of how your child s dental plan works. It is important for your child s health to receive regular dental care. Even if your child is not in pain or having problems with their teeth, they should have a regular checkup as soon as possible. We can help you choose a dentist from our network or we can assign a dentist to provide dental care for your child. Please call member services toll free at (TTY 711 or ) Monday through Friday from 8 a.m. to 5 p.m. EST for help in choosing your child s dentist. We look forward to serving your child s needs. Yours in dental health, DentaQuest W. Liberty Drive Milwaukee, WI

4 HOW TO CONTACT US If you have questions about your child s dental benefits, you can contact DentaQuest by phone, in writing or by visiting our website. Phone Call member services toll free at (TTY 711 or ) Monday through Friday from 8 a.m. to 5 p.m. EST. Mailing address DentaQuest W. Liberty Drive Milwaukee, WI Website DentaQuest member services representatives are specially trained to explain dental treatments and the Healthy Kids program s plan benefits. When you contact them, they can: Verify your child s eligibility for benefits Help you change your child s assigned dentist Send you an ID card replacement Explain your child s benefit plan Refer your child to a dental specialist GETTING STARTED Dental Home DentaQuest believes all children should have a dental home. A dental home is where your child will have an ongoing relationship with a regular dentist no later than age one. Establishing a dental home means your child will receive regular and coordinated oral health care in a family-centered way from a licensed dentist. In order to establish a dental home either you can choose a dentist or DentaQuest will assign a dentist to your child. You can change your child s dentist and dental home at any time by calling DentaQuest. Choosing A Dentist The dentist you choose or the one that is assigned to your child will see your child regularly every six months. This dentist will provide care for your child, work with you to keep your child healthy and provide information about what dental care is needed at each age. When necessary, the dentist will recommend a specialist to treat your child s dental needs. Once you choose a dentist for your child, it is important to keep all appointments and always arrive on time. To choose a dentist: Call member services toll free at (TTY 711 or ) Monday through Friday from 8 a.m. to 5 p.m. EST. You can also visit our website at and follow these steps: Choose FIND A DENTIST in the upper, right corner of the webpage Choose Medicaid/Medicare Choose Florida Under Select State and Health Plan Group, choose Florida Healthy Kids Choose Accepting New and Existing Patients Under Enter your Geographic Area, enter your home, work address or zip code to find a dentist and dental home that is convenient for you 6 7

5 Under Optional Provider Search Criteria, you can search for a dentist you may already see to determine if he or she is in the Florida Healthy Kids network; you can also search by language and special needs Press the Search button at the bottom of the page 4. When you and your child arrive for the appointment, be sure to present your child s ID card. 5. Make sure you understand and discuss your child s treatment plan with the dentist. 6. Before your child begins any treatments, verify that your dental plan covers the procedures. Regular dental check-ups Make sure to call your child s dentist to schedule a regular dental checkup. This will help your child develop good dental health habits. Canceling dental appointments If you have to cancel a dental appointment, please make sure that you call the dental office at least 24 hours in advance. What is the difference between a general dentist and a specialist? A general dentist can perform most of the services that your child will need. However, there are times when your child may need extra attention for services such as extractions and root canals. Using your Child's Dental Benefits To use your child s dental benefits, follow these simple steps: 1. Choose a DentaQuest dentist or contact DentaQuest for the name of the dentist that we have assigned to your child. Call member services toll free at (TTY 711 or ) Monday through Friday from 8 a.m. to 5 p.m. EST. 2. Call your child s dental office and make an appointment. Tell the dental office that your child is a member of DentaQuest and is enrolled in the Healthy Kids program. Specialists receive additional training and concentrate only on providing specific services. For example, oral surgeons concentrate on extracting teeth; periodontists treat gums; endodontists perform root canals and orthodontists put on braces. In most cases, a referral from the general dentist is necessary to go to a specialist. What if my child needs to see a specialist? DentaQuest is contracted with dental specialists in all fields. If your general dentist determines that your child needs to see a specialist, they will refer you to a participating DentaQuest specialist in your area. All specialist referrals must be pre-approved by DentaQuest. 3. Whenever you call to make an appointment, verify that the dentist is still participating in the Healthy Kids program. 8 9

6 CARING FOR YOUR CHILD S TEETH Taking care of your child s teeth will protect your child from tooth decay and give them a healthy smile for life. Tooth decay can: Cause your child pain Make it hard for your child to chew Make your child embarrassed to talk or smile Create problems for your child s adult teeth Make it difficult for your child to learn at school Take these simple steps to prevent tooth decay: Start cleaning your child s teeth as soon as they come in. Teach your child to brush two times a day and floss daily. Protect your child s teeth with fluoride. Give your child healthy, low-sugar foods and drinks. Take your child to the dentist for regular checkups. WHAT ARE MY CHILD'S DENTAL BENEFITS? This is a summary of the dental benefits offered under the Florida Healthy Kids plan. For a copy of the entire benefits, please visit or call DentaQuest member services toll free at (TTY 711 or ). Before obtaining services, please verify that the services your dentist wishes to perform on your child are covered under your plan. Your dentist can help you understand your benefits. All covered services are provided to your child at no charge. However, your dentist may charge you for services which are not covered under the plan. Some exclusions and limitations may also apply to certain services and benefits. Preventive Services Cleanings Topical fluoride application Sealants Space maintainers Oral Examinations X-Rays Fillings and Crowns Extractions and Other Oral Surgery Services Root Canals Periodontal (Gum) Services Dentures (Removable Prosthodontics) Orthodontic (Braces) Services Services are limited to those circumstances where the child's condition creates a disability and impairment to their physical development when the condition severely interferes with the ability to chew or talk. While most children have some tooth crowding or alignment issues, orthodontics is not a covered service in many of these situations. Orthodontic services are not covered for cosmetic purposes. Anesthesia and Sedation Palliative Treatment Hospitalization treatment requires prior authorization Hospitalization for dental treatment is covered only if a child's health is so jeopardized that procedures cannot be safely performed in the dental office; and/or, the child is so uncontrollable due to emotional instability or developmental disability and sedation does not work. The hospital facility service needs to be coordinated with the member s medical health insurance company

7 EXCLUSIONS AND LIMITATIONS Service Requirements DentaQuest pays for services that it determines are medically necessary and do not duplicate another provider s service. According to the State of Florida, medical necessity means the services must meet the following criteria: The services must be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient s needs; The services cannot be experimental or investigational; The services must reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and The services must be furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider. The fact that a participating dentist has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered service. Exclusions Your plan does not cover the following dental services: Application of fluoride to a tooth prior to restoration Restoration on primary teeth if loss is expected within six months Crowns provided solely for aesthetic reasons Fixed bridges or fixed partial dentures Any treatment, which cannot be performed because of the general health and physical limits of the eligible member, as indicated by said member s personal physician, or the dentist/ specialist or the dental director Any dental procedure considered experimental by a participating dentist/specialist or the dental director Dispensing of drugs Any treatment paid for by workers compensation or employer s liability laws, by a federal or state government agency, or other insurance coverage carried by the member. Any treatment provided without cost by any municipality, county or other political subdivision Any dental care provided by a non-participating general dentist or specialist except in emergency cases Services resulting from any act of war, declared or not, or resulting from military services The participating dentist shall have the right to refuse treatment to a member who fails to follow a prescribed course of treatment Any dental treatment started prior to the member s effective date for eligibility of benefits including but not limited to teeth prepared for crowns, root canals in progress and orthodontics; DentaQuest will review any possible exceptions for treatment in progress Consultations for non-covered benefits Implant placement or removal, appliances placed on or services associated with implants Restorations placed solely for cosmetic reasons Extraction of teeth, when teeth are asymptomatic (show no signs of infection) including but not limited to the removal of third molars Treatment or extraction of non-infected primary teeth when normal loss is imminent Accidental injury defined as damage to the hard and soft tissue of the oral cavity resulting from forces external to the mouth (this is usually handled through the member s medical coverage) Periodontal scaling in the absence of root planing No caries or existing amalgam or resin restoration may be present on the surface of the tooth on which a sealant is applied 12 13

8 Partial dentures are not covered: 1) where there are at least eight posterior teeth in occlusion; or 2) for a single tooth replacement unless it is a missing anterior tooth Limitations Fillings are limited to one tooth per surface every three years Composite/resin restorations on posterior teeth are limited to once every three years per tooth surface Sealants are limited to one application per tooth every three years. Sealants are only covered on permanent first and second molars, tooth numbers: 2, 3, 14, 15, 18, 19, 30, 31 Space maintainers are limited to fixed appliances, must be passive in nature and maintain the space for at least 6 months Palliative treatment includes those covered services necessary to relieve pain and discomfort on an emergency basis; palliative treatment is limited to those instances where circumstances contraindicate more definitive treatment or services Root canal therapy is limited to those situations where the teeth have a restorable crown, the prognosis of the tooth is not questionable and the exfoliation of the deciduous tooth is not anticipated within 18 months EMERGENCY DENTAL CARE What is a dental emergency? Constant pain of teeth or gums Uncontrollable bleeding in mouth area Very bad or painful infection Sharp edges caused by broken teeth or damaged braces Tears or cuts inside the mouth Dental swelling with high fever Broken jaw and/or facial bones Dislocated jaw What if my child has a dental emergency? Your child is covered for emergency dental services at participating general dentists. If your child has a dental emergency, please call the dental office your child is assigned to. If you cannot reach the dentist, call DentaQuest at (TTY 711 or ) for emergency assistance. A member services representative will help you find a dentist. Your child is also covered if they have a dental emergency while you are temporarily more than 50 miles from a participating dentist. In that case your child may receive dental services to relieve pain or discomfort. DentaQuest will reimburse you for any covered dental services. You must send the following information to DentaQuest within 12 months of receiving emergency dental services to be reimbursed. The member s name, ID number, address and phone number The paid receipt The dentist s name, address and phone number Any other important information regarding the dental emergency Mail the information to: DentaQuest ATTN: Member Services Department PO Box 2906 Milwaukee, WI Call your dental home dentist for a follow-up appointment if you have taken your child to the emergency room or a dentist outside of your area for an emergency. Your dental home dentist will help you get the care you need

9 RENEW YOUR FLORIDA HEALTHY KIDS DENTAL BENEFITS Your child s dental period is 12 months from the date your child became eligible for the program. Healthy Kids will send you a notification letter when it s time to re-apply. Your coverage does not continue if you do not re-apply. To re-apply or to determine your eligibility for the program, please call COMPLAINTS, GRIEVANCES AND APPEALS What do I do if I have a problem? From time to time you may have questions regarding your dental office or treatment your child has received. We encourage you to discuss these issues with your dentist/dental office first. However, if you cannot resolve the issue with your dentist/dental office we have developed procedures to help you in a timely manner. Call DentaQuest s member services department toll free at Tell the representative about your issues or concerns. Most issues can be fixed by DentaQuest s member services staff. If we cannot fix your problem within 24 hours, we will send your complaint to our Grievances and Appeals Department for further review and your complaint will be processed as a formal grievance. Complaints If you have questions about your child s dental plan or DentaQuest s services, please call us toll free at We will try to handle your questions and complaints quickly. Most questions can be answered by DentaQuest s member services staff. If you are calling to register a complaint, our staff will help to find an answer and resolve your problem. Grievance Process A grievance is when you are not happy with the service you are getting or you feel your child has not been treated well. You can tell us about a grievance verbally or in writing within 12 months of the incident. You can give us more information about your grievance at any time during the process. This can be done in person, on the phone, or in writing. We will look at your grievance and when we finish, we will send you a letter. You also have the right to look at your case file and any other documents involved in the process. If you want to put your grievance in writing, you can write your own letter or ask for a grievance form from our member services department by calling Monday through Friday, from 8 a.m. to 5 p.m. EST. The member services representative can help you complete the grievance form, or one can be mailed to you in three business days. Your child's dentist will also have a copy of the DentaQuest grievance form. Mail or fax the letter or the form to: DentaQuest Grievance & Appeals Department PO Box 2906 Milwaukee, WI Fax: Include your child s name, address, member number, your signature and the date. The Grievance Department will respond to the member in writing regarding the resolution within 60 days of receipt of the grievance. Your dentist, a friend or a family member can make a grievance for you as long as you approve it in writing. To select a person to act for you, DentaQuest needs: A letter with your child's name, member ID, telephone number, address, and your signature telling us this person can act for you Mail or fax the letter to: DentaQuest Grievance & Appeals Department PO Box 2906 Milwaukee, WI Fax: You can ask to add up to 14 calendar days to the process. You can ask for this extra time by writing or calling us. We can also take an extra

10 calendar days if we need more time to get more information that will help us make a decision in your favor. We will send you a letter if we need extra time. The letter will tell you why we need more time. Our Grievance and Appeals Department can be reached at (TTY 711 or ), Monday through Friday from 8 a.m. to 5 p.m. EST. Appeals Process An appeal is when you ask DentaQuest to review a denial of services that your dentist asked for your child. You can ask for this appeal within 30 calendar days after you get our letter about your denial. This process will take no more than 45 calendar days from the date we receive your appeal request either on the phone or in writing. If you appeal verbally, you need to send us a letter within 10 calendar days from the date you talk to us. We will look at your appeal and we will send you a letter within 45 days of when you first asked for the appeal. The letter will tell you what we decided and why. You may request to continue receiving the benefits being denied during the appeal process. If the appeal decision is not in your favor, you may have to pay us back for the services received during this time. You can ask your dentist how much the services would cost if the decision is not in your favor. You can give us more information about your appeal at any time during the process. This can be done in person or in writing. You also have the right to look at your case file and any other documents involved in the process. Contact DentaQuest's member services department to find out if your situation qualifies for an expedited appeal by calling (TTY 711 or ), Monday through Friday from 8 a.m. to 5 p.m. EST. Your benefits will not stop while we are looking at the grievance or appeal. We are here to help you. Call us if you have any questions about grievances or appeals. You can also ask for a review by the Beneficiary Assistance Program. You must ask for a review within 365 days from the date you placed a grievance or received denial on an appeal letter. Call or send a letter to: Subscriber Assistance Program Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 45 Tallahassee, FL Fax: YOU AND YOUR CHILD S RIGHTS AND RESPONSIBILITIES You And Your Child s Rights To be treated with courtesy and respect, with appreciation for you and your child s dignity and with protection of you and your child s privacy To know what member services are available and to be assisted promptly and courteously To know who your child s participating dentist is and to be able to change to another participating dentist To be given information by your child s participating dentist concerning diagnosis, planned course of treatment, alternatives, risk and expected outcomes To refuse treatment and to ask your child s participating dentist about the consequences of refusing treatment To be given access to dental services regardless of you or your child s race, national origin, religion or physical handicap To receive information about your child s dental plan To voice complaints or file a grievance about DentaQuest or the dental services your child has received To participate in making decisions with the participating dentist about your child s dental care Subscriber Assistance Program You can ask for a review by the Subscriber Assistance Program once you have gone through DentaQuest s appeals process

11 You And Your Child s Responsibilities To read the member handbook and familiarize yourself with all of the aspects of the dental plan To cooperate and be respectful of the participating dentist and dental office staff To give the participating dentist and the dental office staff accurate and complete information needed to care for your child To keep your scheduled appointments and be on time. To notify the participating dental office as soon as possible when you can t make an appointment To respect the rights of fellow patients To follow the treatment plan and instructions for dental care for your child that you have agreed to with your participating dentist and dental office staff To carry your child s identification card and present it before your child receives services To pay all charges for missed appointments and services not covered by the dental plan To follow the participating dental office rules and regulations regarding patient care and conduct To receive services only from participating general dentists and specialists except for dental emergencies outside of the service area NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. DENTAQUEST'S POLICIES ARE HIPAA COMPLIANT. Our Legal Duty We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. Uses and Disclosures of Health Information We use and disclose health information about you for treatment, payment, and healthcare operations. For examples: Treatment: We may use or disclose your health information to a dentist or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to make payments for services provided to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice

12 Giving Disclosure to Family and Friends: We must disclose your health information to you, as described in the Member Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Person Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, or your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up dental payment records, dental records, study models, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or member under certain circumstances. Members Rights Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.05 for each page, no charge for staff time to locate and copy your healthy information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request

13 Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Website or by electronic mail ( ), you are entitled to print this Notice from our Website or request a copy by mail using the contact information listed at the end of this Notice. Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, if you disagree with a decision we made about access to your health information, if you have questions about our response to a request you made to amend or restrict the use or disclosure of your health information, or if you would like to have us communicate with you by alternative means or at alternative locations; you may contact us using the information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Office: Kara Rutledge Telephone: (617) Fax: (617) Kara.Rutledge@greatdentalplans.com Address: DentaQuest 465 Medford Street Boston, Massachusetts Dental Records: Participating dentists are required to keep records and charts of all dental services rendered to members in accordance with the Florida Dental Practice Act and Regulations. These records are the property of the participating dentist. Upon enrollment the member authorizes DentaQuest to request and obtain, for use exclusively by DentaQuest, member records, radiographs or any other information from any dentist that has rendered treatment to the member. Upon the request of the member, the participating dentist will furnish copies of x-rays and service records. The participating dentist has the right to charge the member an amount not to exceed the amount charged by the Clerk of Courts for the specific county in which the dental office is located for photocopies of dental records and copies of x-rays requested by the member. Neither any participating dentist nor DentaQuest will be required to transfer any original records or x-rays, unless required by law. Independent Dental Facilities: The Plan contracts with independently owned dental offices. All participating dentists agree to perform their obligations in accordance with prevailing professional standards of the dental profession, to maintain in full force and effect professional liability (malpractice) insurance and to maintain general and premises liability insurance in reasonable amounts of coverage to cover damage to person or property of members. DentaQuest is not liable for any damage or injury to person or property resulting directly or indirectly from the negligent act or omission of or malpractice of a participating dentist or any other dentist or auxiliary providing service to a member, whether of an emergency nature or any otherwise, or for any other damage or injury to person or property resulting from, arising out of or in any way connected with any defective or dangerous conditions in, on, around, or about a dental office or such other office or dental facility which may provide a service to a member. The Plan will not be liable or responsible for any financial agreements made between a participating dentist and a member. Third Party Injury: If the services rendered, are required due to injury caused by the negligence of a third party person, and if the member receives a recovery against the negligent party, or if the member receives Workers Compensation or insurance benefits, then any participating dentist shall be entitled to charge and collect from the member, his/her usual, customary and reasonable fees for any dental services rendered up to the time and to the extent of recovery for such dental services

14 DENTAL TERMS Abscess: A localized inflammation due to a collection of pus in the bone or soft tissue, usually caused by an infection Amalgam/Filling: Silver filling used to fill holes in teeth caused by decay Anesthesia: A drug used by a dentist to put the mouth to sleep so that the patient doesn t feel any pain during dental procedures Biopsy: To remove and examine tissue, cells, or fluids from the living body Cavity/Caries: A hole in one of the teeth caused by decay Composite/Filling: White fillings used to fill holes in teeth caused by decay. Usually used in front teeth Crown: Also called a cap, a lab-fabricated (made in a lab) false tooth used to restore a tooth that has heavy decay, a fracture or a root canal Curettage: A periodontal procedure where the gums are scraped below the gum line to remove bacteria Denture: A lab-fabricated complete replacement of the upper and/or lower teeth Extraction: Removal of a tooth Fluoride: Gel applied to the top of teeth after a cleaning is done. Fluoride helps prevent tooth decay by stopping the breakdown of enamel Intraoral: Inside your mouth Partial: A lab-fabricated partial replacement of your upper and/or lower teeth Periapical: The area surrounding the root tip of a tooth Plaque: A sticky, white film of bacteria that forms on teeth, causing tooth decay, swelling of the gums, periodontal disease, and bad breath Prefabricated: Made in a lab Prophylaxis/Cleaning: Cleaning, scaling and polishing procedure performed to remove plaque, tartar and stains from teeth above the gum line Pulp: The blood vessels and nerves that are inside of a tooth Pulpotomy: Removal of the top portion of the pulp Sealant: Protective plastic coating that covers grooves in healthy teeth to stop decay Root Canal: Removal of the pulp inside a tooth due to heavy decay and/ or fracture Space Maintainer: An appliance put in the mouth to stop drifting and crowding of teeth after a baby tooth is taken out X-Rays/Radiographs: A picture of teeth and gums that helps the dentist determine treatment; types of X-rays include bitewings and panoramic Gingivitis: The inflammation of the gums caused by improper brushing. The first sign of gum disease Impacted Tooth: A tooth that needs assistance to break through the gums 26 27

15 28 29 NOTES: NOTES:

16 11100 W. Liberty Drive Milwaukee, WI Toll Free: Reference #: 5033 HB/EN (8.17)