Enablemed Dental Benefit Table
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1 Enablemed Dental Benefit Table 2018 MAKOTI PRIMARY OPTION DENTAL BENEFIT TABLE 2018 MAKOTI COMPREHENSIVE OPTION DENTAL BENEFIT TABLE 2018 Dental benefits are paid at the scheme tariff. Hospitalisation and certain specialised dentistry procedures must be preauthorised*. If no pre-authorisation is obtained or if pre-authorisation is applied for after the treatment has been done, benefits will not apply for crowns, periodontics, IV/conscious sedation and hospitalisation. Failure to pre-authorise orthodontic treatment will result in a payment ONLY from date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated. Pre-authorisation does not apply to emergency hospital admissions. Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event of a dispute, the registered rules of the scheme prevail. Dentures* must be pre-authorised on the Comprehensive option. Please note that all Specialised Dentistry benefits for the Makoti Comprehensive Option are subject to a limit of R2 862 per family per year. This includes Partial Metal Frame Dentures, Crown & Bridge, Orthodontics, Periodontics and Maxillo-facial Surgery. MAKOTI PRIMARY OPTION MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family One annual check-up per beneficiary. One annual check-up per beneficiary. Consultations CONSERVATIVE DENTISTRY X-rays: Intra-oral X-rays: Extra-oral One per beneficiary in a 3-year period. One per beneficiary in a 3-year period. Additional benefit may be granted where specialised dental treatment is required. 1
2 Oral Hygiene Fillings MAKOTI PRIMARY OPTION One annual scale and polish treatment per beneficiary. Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Oral hygiene instructions Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Dental bleaching Benefit for fillings will be granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols. A treatment plan and X-rays may be required for multiple fillings. Benefit for more than three fillings per beneficiary is subject to pre-notification. Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis Resin bonding for restorations that are charged as a separate procedure to the restoration The polishing of restorations Gold foil restorations Ozone therapy MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family One annual scale and polish treatment per beneficiary. Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Oral hygiene instructions Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Dental bleaching Benefit for fillings will be granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols. A treatment plan and X-rays may be required for multiple fillings. Benefit for more than three fillings per beneficiary is subject to pre-notification. Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis Resin bonding for restorations that are charged as a separate procedure to the restoration The polishing of restorations Gold foil restorations Ozone therapy 2
3 Root Canal Therapy and Extractions MAKOTI PRIMARY OPTION Benefit for extractions is only available for procedure codes 8201 and Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (third molars) Direct and indirect pulp capping procedures MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (third molars) Direct and indirect pulp capping procedures One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period. Plastic Dentures* Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. Diagnostic dentures and associated laboratory costs Snoring appliances and associated laboratory costs High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Laboratory delivery fees Provisional dentures and associated laboratory costs 3
4 MAKOTI PRIMARY OPTION MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family SPECIALISED DENTISTRY Partial Metal Frame Dentures* and Associated Laboratory Costs One partial frame (an upper or a lower) per beneficiary in a 5-year period. The metal base to full dentures and associated laboratory costs High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Laboratory delivery fees Benefits for crowns are granted once per tooth in a 5-year period Crown & Bridge* & Associated Laboratory Costs A bridge comprises two or more crown units. Each crown is payable from the available Crown & Bridge benefit. A treatment plan and X-rays may be requested. Crowns or crown retainers on wisdom teeth (third molars) Pontics on second molars where the third molar is a retainer Crown and bridge procedures for cosmetic reasons and associated laboratory costs Occlusal rehabilitations and associated laboratory costs Provisional crowns and associated laboratory costs Porcelain veneers and inlays and associated laboratory costs Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs. 4
5 MAKOTI PRIMARY OPTION MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family Implants* and Associated Laboratory Costs The cost of gold, precious metal, semiprecious metal and platinum foil Laboratory delivery fees On pre-authorisation, cases will be clinically assessed by using an orthodontic needs analysis and funding can be granted up to 100% of the scheme orthodontic tariff per beneficiary per lifetime. SPECIALISED DENTISTRY Orthodontics* and Associated Laboratory Costs Benefit for orthodontic treatment will be granted where function is impaired. Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered. Only one family member may commence orthodontic treatment in a calendar year. Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age. Orthognathic (jaw correction) and other orthodontic related surgery and any related hospital and laboratory costs Orthodontic re-treatment and any related laboratory costs Invisible retainer material Laboratory delivery fees Periodontics* Benefit is subject to managed care protocols. Benefit is limited to conservative, nonsurgical therapy only and will only be applied 5
6 MAKOTI PRIMARY OPTION MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family to members who are registered on the Periodontal Programme. Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemisection of a tooth Perio chip placement 6
7 MAKOTI PRIMARY OPTION Surgery in the dental chair: Benefit only available for the following procedure codes: 8931, 8935, 9011 and MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family Surgery in the dental chair: Temporo-mandibular joint (TMJ) therapy: Benefit is limited to non-surgical intervention/treatments. Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours): Claims will only be covered if supported by a laboratory report that confirms diagnosis. SPECIALISED DENTISTRY Maxillo-facial Surgery and Oral Pathology Surgery in hospital: See Hospitalisation* below Orthognathic (jaw correction) surgery Sinus lifts Bone augmentations Bone and tissue regeneration procedures The cost of bone regeneration material The auto-transplantation of teeth The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) Surgery in hospital: See Hospitalisation* below 7
8 MAKOTI PRIMARY OPTION MAKOTI COMPREHENSIVE OPTION Specialised Dentistry limit R2 862 per family HOSPITALISATION AND ANAESTHETICS Hospitalisation (General Anaesthetic)* Laughing Gas in Dental Rooms IV/Conscious Sedation in Rooms* Admission protocols apply. PMB admissions only. Pre-authorisation required. Benefit is limited to extensive dental treatment. Admission protocols apply. Impacted teeth removal and PMB admissions only. Pre-authorisation required. Benefit is limited to extensive dental treatment. Additional Electrognathographic recordings, pantographic recordings and other such electronic analyses Nutritional and tobacco counseling Caries susceptibility and microbiological tests Fissure sealants on patients 16 years and older Pulp tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony including dento-legal fees Treatment plan completed (currently code 8120) Enamel microabrasion Behaviour management Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures 8
9 GOMOMO CARE DENTAL BENEFIT TABLE 2018 Dental benefits are paid at the Sizwe Dental tariff (SDT). Dental benefits are subject to managed care protocols and managed care interventions at a DENIS Designated Service Provider Network for Dentists which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event of a dispute, the registered rules of the scheme prevail. Dentures* must be pre-authorised on the Gomomo option. If no authorisation or late authorisation is obtained before commencing IV/conscious sedation, no benefits will apply. The benefits are subject to an annual family limit for dentistry. The family limit amount is calculated according to the number of lives on the membership (see table below). Number of Lives Annual Family Limit Member R Member + 1 R3 190 Member + 2 R3 470 Member + 3 R3 750 Member + 4 R4 010 Member + 5 R4 290 Member + 6 R4 710 One annual check-up per beneficiary. GOMOMO CARE OPTION Consultations CONSERVATIVE DENTISTRY X-rays: Intra-oral X-rays: Extra-oral One per beneficiary in a 3-year period. 9
10 GOMOMO CARE OPTION One annual scale and polish treatment per beneficiary. Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. Oral Hygiene Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Oral hygiene instructions Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Dental bleaching CONSERVATIVE DENTISTRY Fillings Benefit for fillings will be granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols. A treatment plan and X-rays may be required for multiple fillings. Benefit for more than three fillings per beneficiary is subject to pre-notification. Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis Resin bonding for restorations that are charged as a separate procedure to the restoration The polishing of restorations Gold foil restorations Ozone therapy Root Canal Therapy and Extractions Benefit for extractions is only available for procedure codes 8201 and Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (third molars) Direct and indirect pulp capping procedures 10
11 GOMOMO CARE OPTION One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period. CONSERVATIVE DENTISTRY Plastic Dentures* Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. Diagnostic dentures and associated laboratory costs Snoring appliances and associated laboratory costs High impact acrylic The cost of gold, precious metal, semi-precious metal and platinum foil Laboratory delivery fees Provisional dentures and associated laboratory costs Partial Metal Frame Dentures and Associated Laboratory Costs SPECIALISED DENTISTRY Crown & Bridge* and Associated Laboratory Costs A bridge comprises two or more crown units. Each crown is payable from the available Crown & Bridge benefit. Implants* and Associated Laboratory Costs Orthodontics* and Associated Laboratory Costs 11
12 GOMOMO CARE OPTION Periodontics* Surgery in the dental chair: CONSERVATIVE DENTISTRY Maxillo-facial Surgery and Oral Pathology Benefit only available for the following procedure codes: 8931, 8935, 9011 and 9013 HOSPITALISATION AND ANAESTHETICS Hospitalisation (General Anaesthetic)* Laughing Gas in Dental Rooms IV/Conscious Sedation in Rooms* Admission protocols apply. PMB admissions only. Managed by SECHABA. Pre-authorisation required. Benefit is limited to extensive dental treatment. Additional Electrognathographic recordings, pantographic recordings and other such electronic analyses Nutritional and tobacco counseling Caries susceptibility and microbiological tests Fissure sealants on patients 16 years and older Pulp tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony including Dento-legal fees Treatment plan completed (currently code 8120) Enamel microabrasion Behaviour management 12
13 Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures 13
14 MALCOR OPTION D DENTAL BENEFIT TABLE 2018 Dental benefits are paid at the scheme tariff. Hospitalisation and IV/conscious sedation must be pre-authorised*. If no preauthorisation is obtained or if pre-authorisation is applied for after the treatment has been done, benefits will not apply. This does not apply to emergency hospital admission. Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event of a dispute, the registered rules of the scheme prevail. Dentures* must be pre-authorised on Malcor Option D. MALCOR OPTION D One annual check-up per beneficiary. Consultations X-rays: Intra-oral CONSERVATIVE DENTISTRY X-rays: Extra-oral One per beneficiary in a 3-year period. One annual scale and polish treatment per beneficiary. Oral Hygiene Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Oral hygiene instructions Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Dental bleaching 14
15 MALCOR OPTION D Benefit for fillings will be granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols. Fillings A treatment plan and X-rays may be required for multiple fillings. Benefit for more than three fillings per beneficiary is subject to pre-notification. Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis Resin bonding for restorations that are charged as a separate procedure to the restoration The polishing of restorations Gold foil restorations Ozone therapy CONSERVATIVE DENTISTRY Root Canal Therapy and Extractions Benefit for extractions is only available for procedure codes 8201 and Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (third molars) Direct and indirect pulp capping procedures One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period. Plastic Dentures* Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. Diagnostic dentures and associated laboratory costs Snoring appliances and associated laboratory costs High impact acrylic The cost of gold, precious metal, semi-precious metal and platinum foil Laboratory delivery fees 15
16 MALCOR OPTION D Provisional dentures and associated laboratory costs Partial Metal Frame Dentures and Associated Laboratory Costs Crown & Bridge and Associated Laboratory Costs SPECIALISED DENTISTRY A bridge comprises two or more crown units. Each crown is payable from the available Crown & Bridge benefit. Implants and Associated Laboratory Costs Orthodontics and Associated Laboratory Costs Periodontics Maxillo-facial Surgery and Oral Pathology Surgery in the dental chair: Benefit only available for the following procedure codes: 8931, 8935, 9011 and Surgery in hospital: See Hospitalisation* below HOSPITALISATION AND ANAESTHETICS Hospitalisation (General Anaesthetic)* Laughing Gas in Dental Rooms Admission protocols apply. PMB admissions only. 16
17 MALCOR OPTION D Pre-authorisation required. HOSPITALISATION AND ANAESTHETICS Conscious Sedation in Rooms* Benefit is limited to extensive dental treatment. Additional Electrognathographic recordings, pantographic recordings and other such electronic analyses Nutritional and tobacco counseling Caries susceptibility and microbiological tests Fissure sealants on patients 16 years and older Pulp tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony including dento-legal fees Treatment plan completed (currently code 8120) Enamel microabrasion Behaviour management Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures 17
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assignment_id service_code Topic Subtopic Long Names 239 D3346 Root Canal Procedure Retreatment 240 D3347 Root Canal Procedure Retreatment 241 D3348 Root Canal Procedure Retreatment 242 D3425 Root Canal
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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
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