Sizwe Medical Fund Dental Benefit Table

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1 Sizwe Medical Fund Dental Benefit Table 2017 PRIMARY CARE DENTAL BENEFIT TABLE 2017 DENTAL BENEFIT TABLE 2017 DENTAL BENEFIT TABLE 2017 Dental benefits are paid at the Sizwe Dental tariff (SDT). Hospitalisation and certain specialised dentistry, and treatments must be pre-authorised*. Procedures and treatment not authorised will not be eligible for funding. If authorisation is approved after the treatment has been done, a 20% penalty will apply. This is applicable to hospitalisation (the hospital account) and for the following specialised out-of-hospital dentistry treatments: crowns and bridges, implants, periodontics and IV conscious sedation in the dental rooms. 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 approved as per the Penalties do not apply to emergency/pmb** 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 rules of the scheme will prevail. Primary Care: Voluntary admissions in hospitals that are not participating in the scheme s Hospital DSP Network will be subjected to a co-payment of 20% (the hospital account). ** PMB = Prescribed Minimum Benefits NOTE: In 2017 Family Limits are applicable to both Conservative and. The Orthodontic, Crown and Bridge and Implant Benefit is NOT subject to the Limit. PRIMARY CARE Limit CONSERVATIVE DENTISTRY Consultations 2 annual check-ups per beneficiary (once in 6 months). 2 annual check-ups per beneficiary (once in 6 months). 2 annual check-ups per beneficiary (once in 6 months). X-rays: Intra-oral 1

2 Limit X-rays: Extra-oral 1 per beneficiary in a 3 year period. 1 per beneficiary in a 3 year period. 1 per beneficiary in a 3 year period. Additional benefit may be considered where specialised dental treatment is Additional benefit may be considered where specialised dental treatment is Oral Hygiene 2 annual scale and polish treatments per beneficiary (once in 6 months). 2 annual scale and polish treatments per beneficiary (once in 6 months). 2 annual scale and polish treatments per beneficiary (once in 6 months). Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age. 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. Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13 years of age. Oral hygiene instruction Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Oral hygiene instruction Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older Oral hygiene instruction Oral hygiene evaluation Professionally applied fluoride for beneficiaries 13 years and older 2

3 Limit Dental bleaching Dental bleaching Dental bleaching Fillings Benefit for fillings are granted once per tooth in 365 days. Benefit for fillings are granted once per tooth in 365 days. Benefit for fillings are granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols. Benefit for re-treatment of a tooth is subject to Benefit for re-treatment of a tooth is subject to A treatment plan and x-rays may be required for multiple fillings. A treatment plan and x- rays may be required for multiple fillings. A treatment plan and x- rays may be required for multiple fillings. 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 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 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 3

4 Limit Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (3rd molars) Direct and indirect pulp capping Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (3rd molars) Direct and indirect pulp capping Root canal therapy on primary (milk) teeth Root canal therapy on wisdom teeth (3rd molars) Direct and indirect pulp capping Plastic Dentures and associated Laboratory 1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4 year period. 1 set of plastic dentures full or partial (an upper and a lower) per beneficiary in a 4 year period. 1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4 year period. 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 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 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. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. 4

5 Limit Diagnostic dentures and Snoring appliances and High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Provisional dentures and Diagnostic dentures and Snoring appliances and High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Provisional dentures and Diagnostic dentures and Snoring appliances and High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Provisional dentures and SPECIALISED DENTISTRY Partial Metal Frame Dentures and associated Laboratory No benefit 2 partial frames (an upper and a lower) per beneficiary in a 5 year period, limited to 1 family member per annum. 2 partial frames (an upper and a lower) per beneficiary in a 5 year period, limited to 2 family members per annum. The metal base to full dentures and High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil The metal base to full dentures and associated laboratory High impact acrylic The cost of gold, precious metal, semiprecious metal and platinum foil Crown & Bridge* and associated Laboratory No benefit 1 crown per family per 3 crowns per family per 5

6 Limit A bridge comprises 2 or more crown units. Each crown is payable from the available Crown and Bridge benefit. year. Benefits for crowns are granted once per tooth in a 5 year period. year. Benefits for crowns are granted once per tooth in a 5 year period. Note: NOT subjected to the Specialised Dentistry Limit A treatment plan and x- rays may be requested. Crown or crown retainers on wisdom teeth (3rd molars) Pontics on 2nd molars Crown and bridge for cosmetic reasons and associated laboratory Occlusal rehabilitations and Provisional crowns and Porcelain veneers and inlays and associated laboratory Emergency crowns that are not placed for the immediate protection in tooth injury and The cost of gold, precious metal, semiprecious metal and platinum foil A treatment plan and x- rays may be requested. Crown or crown retainers on wisdom teeth (3rd molars) Pontics on 2nd molars Crown and bridge for cosmetic reasons and associated laboratory Occlusal rehabilitations and associated laboratory Provisional crowns and Porcelain veneers and inlays and associated laboratory Emergency crowns that are not placed for the immediate protection in tooth injury and The cost of gold, precious metal, semiprecious metal and platinum foil 6

7 Limit Implants* and associated Laboratory Note: NOT subjected to the Specialised Dentistry Limit No benefit No benefit 2 implants per beneficiary in a 5 year period. Cost of implant component is limited to R3 500 per implant. Implants on wisdom teeth (3rd molars) Dolder bars and associated abutments on implants including the Orthodontics* and associated Laboratory Note: NOT subjected to the Specialised Dentistry Limit No benefit managed care protocols and will only be funded from date of authorisation. On pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 65% of SDT. required managed care protocols and will only be funded from date of authorisation. On pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 100% of SDT. 7

8 Limit Benefit for Orthodontic treatment will be granted where function is impaired. 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 will also not be covered. Benefit will not be granted where Orthodontic treatment is required for cosmetic reasons. The associated Laboratory will also not be covered. Only one family member may commence Orthodontic treatment in a calendar year. 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. Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age. Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory Orthodontic re-treatment and any related laboratory Invisible retainer material Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory Orthodontic re-treatment and any related laboratory Invisible retainer material Periodontics* Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the 8

9 Limit Periodontal Programme. Periodontal Programme. Periodontal Programme. Surgical Periodontics no benefit. Surgical Periodontics no benefit. Surgical Periodontics subject to managed care protocols. Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth Perio chip placement Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth Perio chip placement Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth Perio chip placement Maxillo-Facial Surgery and Oral Pathology Surgery in the dental chair: Surgery in the dental chair: Surgery in the dental chair: Benefit for Temporomandibular Joint (TMJ) therapy is limited to nonsurgical intervention/ treatments. Benefit for Temporomandibular Joint (TMJ) therapy is limited to nonsurgical intervention/ treatments. Benefit for Temporomandibular Joint (TMJ) therapy is limited to nonsurgical intervention/ treatments. The claims for oral pathology (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if The claims for oral pathology (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will The claims for oral pathology (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will 9

10 supported by a laboratory report that confirms diagnosis. Orthognathic (jaw correction) surgery Bone augmentations Bone and tissue regeneration The cost of bone regeneration material The auto-transplantation of teeth Sinus lift The closure of an oralantral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. Limit only be covered if supported by a laboratory report that confirms diagnosis. Orthognathic (jaw correction) surgery Bone augmentations Bone and tissue regeneration The cost of bone regeneration material The auto-transplantation of teeth Sinus lift The closure of an oralantral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. only be covered if supported by a laboratory report that confirms diagnosis. Orthognathic (jaw correction) surgery Bone augmentations Bone and tissue regeneration The cost of bone regeneration material The auto-transplantation of teeth Sinus lift The closure of an oralantral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. Surgery in hospital: See Hospitalisation* below Surgery in hospital: See Hospitalisation* below Surgery in hospital: See Hospitalisation* below 10

11 Limit HOSPITALISATION AND ANAESTHETICS Hospitalisation (general anaesthetic)* required A co-payment of R1 500 per hospital admission applies. Admission protocols apply. General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment. A co-payment of R1 500 per hospital admission applies. Admission protocols apply. General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment. A co-payment of R1 500 per hospital admission applies. Admission protocols apply. General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment. General anaesthetic benefits are available for the removal of impacted teeth. General anaesthetic benefits are available for the removal of impacted teeth. General anaesthetic benefits are available for the removal of impacted teeth. The Hospital and anaesthetist claims for the following will not be covered when performed under general anaesthesia. The Hospital and anaesthetist claims for the following will not be covered when performed under general anaesthesia. The Hospital and anaesthetist claims for the following will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits and payable at SDT: The payment of the dental procedure will be dependent on available benefits and payable at SDT: The payment of the dental procedure will be dependent on available benefits and payable at SDT: Apicectomies Dentectomies Frenectomies Implantology and associated surgical Apicectomies Dentectomies Frenectomies Implantology and associated surgical Apicectomies Dentectomies Frenectomies Implantology and associated surgical 11

12 Limit Implantology and associated surgical Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene Surgical tooth exposure for orthodontic reasons Implantology and associated surgical Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene Surgical tooth exposure for orthodontic reasons Implantology and associated surgical Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene Surgical tooth exposure for orthodontic reasons Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility. The cost of dental materials for performed under general anaesthetia Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility. The cost of dental materials for performed under general anaesthesia Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility. The cost of dental materials for performed under general anaesthesia Laughing gas in dental rooms IV conscious sedation in rooms* Benefit is limited to extensive dental treatment. Benefit is limited to extensive dental treatment. Benefit is limited to extensive dental treatment. 12

13 Additional scheme exclusions: 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 that are defined as unlisted Primary specific exclusions: Specialised dentistry: crowns & bridges, implants, orthodontics and surgical periodontics Metal base to full dentures Partial metal frame dentures 13

14 SIZWE HOSPITAL CARE (previously known as Sizwe Savings Care) DENTAL BENEFIT TABLE 2017 Dental benefits are paid at the Sizwe dental tariff (SDT). Dental treatment in hospital and under IV conscious sedation in the dental rooms must be pre-authorised*. If no pre-authorisation is obtained: In-hospital: If authorisation is approved after the treatment has been done, a 20% penalty will apply on the hospital account. Penalties do not apply to emergency/pmb** hospital admission. Out of hospital: If authorisation for IV conscious sedation is approved after the treatment has been done, a 20% penalty will apply. 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 rules of the scheme will prevail. ** PMB = Prescribed Minimum Benefits SIZWE HOSPITAL CARE OPTION CONSERVATIVE DENTISTRY Consultations X-rays: Intra-oral X-rays: Extra-oral Oral Hygiene Fillings Root Canal Therapy and Extractions Plastic Dentures and associated Laboratory 14

15 SIZWE HOSPITAL CARE OPTION SPECIALISED DENTISTRY Partial Metal Frame Dentures and associated Laboratory Crown & Bridge and associated Laboratory Implants Orthodontics and associated Laboratory Periodontics Maxillo-Facial Surgery and Oral Pathology in Rooms ( excluding removal of impacted teeth under IV conscious sedation) 15

16 SIZWE HOSPITAL CARE OPTION HOSPITALISATION AND ANAESTHETICS Hospitalisation (general anaesthetic)* Laughing gas in dental rooms IV conscious sedation in rooms* A co-payment of R1 500 per hospital admission applies. Admission protocols apply. General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment. General anaesthetic benefits are available for the removal of impacted teeth. Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility. The cost of dental materials for performed under general anaesthesia Limited to the In-Hospital dental benefits. Additional scheme exclusions: 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 that are defined as unlisted 16

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