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Super SmartSmile Plan
Schedule of Covered Services and Copayments
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
According to office
policy
missed appointmentD9986
According to office
policy
cancelled appointmentD9987
4Office Visit
NC indicates the procedure is not covered
Diagnostic
0 45periodic oral evaluation - established patient
D0120
0 45limited oral evaluation - problem focusedD0140
0 45oral evaluation for a patient under three years of age and counseling with primary caregiver
D0145
0 45comprehensive oral evaluation - new or established patient
D0150
0 0detailed and extensive oral evaluation - problem focused, by report
D0160
0 0re-evaluation - limited, problem focused (established patient; not post-operative visit)
D0170
0 0re-evaluation – post-operative office visitD0171
0 0comprehensive periodontal evaluation - new or established patient
D0180
0 65intraoral - complete series of radiographic images
D0210
0 12intraoral - periapical first radiographic image
D0220
0 8intraoral - periapical each additional radiographic image
D0230
0 0intraoral - occlusal radiographic imageD0240
0 0extraoral - first radiographic imageD0250
0 0extraoral - each additional radiographic image
D0260
0 0bitewing - single radiographic imageD0270
0 21bitewings - two radiographic imagesD0272
0 0bitewings - three radiographic imagesD0273
0 30bitewings - four radiographic imagesD0274
0 0vertical bitewings - 7 to 8 radiographic images
D0277
0 55panoramic radiographic imageD0330
10 NCcephalometric radiographic imageD0340
0 NC2D oral/facial photographic image obtained intra-orally or extra-orally
D0350
5 NCinterpretation of diagnostic image by a practitioner not associated with capture of the image, including report
D0391
20 NCcollection of microorganisms for culture and sensitivity
D0415
15 NCcaries susceptibility testsD0425
10 NCadjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
D0431
0 NCpulp vitality tests D0460
5 NCdiagnostic castsD0470
10 NCcaries risk assessment and documentation, with a finding of low risk
D0601
10 NCcaries risk assessment and documentation, with a finding of moderate risk
D0602
10 NCcaries risk assessment and documentation, with a finding of high risk
D0603
Preventive
0 30prophylaxis - adult (limited to 1 per 6 months & additional at higher copayments)
D1110
80 NCProphylaxis - adult (additional beyond 1 in 6 months)
D1110
0 40prophylaxis - child (limited to 1 per 6 months & additional at higher copayments)
D1120
80 NCProphylaxis - child (additional beyond 1 in 6 months)
D1120
12 36topical application of fluoride varnishD1206
0 26topical application of fluoride – excluding varnish
D1208
0 NCnutritional counseling for control of dental disease
D1310
0 0tobacco counseling for the control and prevention of oral disease
D1320
0 0oral hygiene instructionsD1330
5 35sealant - per toothD1351
20 0preventive resin restoration in a moderate to high caries risk patient – permanent tooth
D1352
5 35sealant repair – per toothD1353
Space Maintainers
40 210space maintainer - fixed - unilateralD1510
60 290space maintainer - fixed - bilateralD1515
30 240space maintainer - removable - unilateralD1520
40 300space maintainer - removable - bilateralD1525
0 48re-cement or re-bond space maintainerD1550
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
0 0removal of fixed space maintainerD1555
Amalgam Restorations - Primary or Permanent
0 60amalgam - one surface, primary or permanent
D2140
0 80amalgam - two surfaces, primary or permanent
D2150
0 95amalgam - three surfaces, primary or permanent
D2160
0 115amalgam - four or more surfaces, primary or permanent
D2161
Resin-Based Composite Restorations
20 78resin-based composite - one surface, anterior
D2330
33 100resin-based composite - two surfaces, anterior
D2331
46 120resin-based composite - three surfaces, anterior
D2332
60 140resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2335
60 200resin-based composite crown, anteriorD2390
85 85resin-based composite - one surface, posterior
D2391
120 115resin-based composite - two surfaces, posterior
D2392
150 143resin-based composite - three surfaces, posterior
D2393
160 175resin-based composite - four or more surfaces, posterior
D2394
Crowns - Single Restoration Only
*Additional charges of $125 for noble metal, $150 for high noble metal. Add $100 for porcelain on molars, $50 for porcelain butt margin, $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc. Copayments only apply when implant is performed by a participating general dentist.
200 NCinlay - metallic - one surface*D2510
200 NCinlay - metallic - two surfaces*D2520
200 NCinlay - metallic - three or more surfaces*D2530
200 NConlay - metallic - two surfaces*D2542
200 NConlay - metallic - three surfaces*D2543
200 NConlay - metallic - four or more surfaces*D2544
340 NCinlay - porcelain/ceramic - one surfaceD2610
340 NCinlay - porcelain/ceramic - two surfaces D2620
340 NCinlay - porcelain/ceramic - three or more surfaces
D2630
340 NConlay - porcelain/ceramic - two surfacesD2642
340 NConlay - porcelain/ceramic - three surfacesD2643
340 NConlay - porcelain/ceramic - four or more surfaces
D2644
230 NCinlay - resin-based composite - one surface
D2650
250 NCinlay - resin-based composite - two surfaces
D2651
250 NCinlay - resin-based composite - three or more surfaces
D2652
250 NConlay - resin-based composite - two surfaces
D2662
250 NConlay - resin-based composite - three surfaces
D2663
250 NConlay - resin-based composite - four or more surfaces
D2664
120 330crown - resin-based composite (indirect)D2710
120 306crown - ¾ resin-based composite (indirect)
D2712
120 300crown - resin with high noble metal*D2720
120 450crown - resin with predominantly base metal
D2721
120 NCcrown - resin with noble metal*D2722
240 NCcrown - porcelain/ceramic substrateD2740
240 380crown - porcelain fused to high noble metal
*D2750
240 470crown - porcelain fused to predominantly base metal
D2751
240 470crown - porcelain fused to noble metal*D2752
225 NCcrown - 3/4 cast high noble metal*D2780
225 NCcrown - 3/4 cast predominantly base metal
D2781
225 NCcrown - 3/4 cast noble metal *D2782
240 NCcrown - 3/4 porcelain/ceramic D2783
225 270crown - full cast high noble metal*D2790
225 420crown - full cast predominantly base metal
D2791
225 295crown - full cast noble metal*D2792
225 NCcrown - titanium*D2794
200 NCprovisional crown– further treatment or completion of diagnosis necessary prior to final impression
D2799
Other Restorative Services
15 NCre-cement or re-bond inlay, onlay, veneer or partial coverage restoration
D2910
15 30re-cement or re-bond indirectly fabricated or prefabricated post and core
D2915
15 44re-cement or re-bond crownD2920
35 45reattachment of tooth fragment, incisal edge or cusp
D2921
50 145prefabricated porcelain/ceramic crown – primary tooth
D2929
50 135prefabricated stainless steel crown - primary tooth
D2930
50 145prefabricated stainless steel crown - permanent tooth
D2931
50 160prefabricated resin crownD2932
70 160prefabricated stainless steel crown with resin window
D2933
70 156prefabricated esthetic coated stainless steel crown - primary tooth
D2934
0 60protective restorationD2940
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
60 120interim therapeutic restoration – primary dentition
D2941
10 60restorative foundation for an indirect restoration
D2949
25 110core buildup, including any pins when required
D2950
20 30pin retention - per tooth, in addition to restoration
D2951
60 180post and core in addition to crown, indirectly fabricated
D2952
0 0each additional indirectly fabricated post - same tooth
D2953
55 78prefabricated post and core in addition to crown
D2954
55 NCpost removal D2955
0 NCeach additional prefabricated post - same tooth
D2957
220 NClabial veneer (resin laminate) - chairsideD2960
260 NClabial veneer (resin laminate) - laboratoryD2961
340 NClabial veneer (porcelain laminate) - laboratory
D2962
50 0temporary crown (fractured tooth)D2970
25 25additional procedures to construct new crown under existing partial denture framework
D2971
200 390copingD2975
5 35resin infiltration of incipient smooth surface lesions
D2990
Endodontics
10 40pulp cap - direct (excluding final restoration)
D3110
4 40pulp cap - indirect (excluding final restoration)
D3120
15 135therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
D3220
15 140pulpal debridement, primary and permanent teeth
D3221
15 135partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
D3222
45 210pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
D3230
55 225pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
D3240
100 450endodontic therapy, anterior tooth (excluding final restoration)
D3310
175 525endodontic therapy, bicuspid tooth (excluding final restoration)
D3320
300 645endodontic therapy, molar (excluding final restoration)
D3330
45 NCtreatment of root canal obstruction; non-surgical access
D3331
70 NCincomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3332
45 NCinternal root repair of perforation defectsD3333
150 520retreatment of previous root canal therapy - anterior
D3346
250 575retreatment of previous root canal therapy - bicuspid
D3347
350 700retreatment of previous root canal therapy - molar
D3348
30 230apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.)
D3351
30 155apexification/recalcification – interim medication replacement
D3352
30 260apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)
D3353
30 230pulpal regeneration - initial visitD3355
30 155pulpal regeneration - interim medication replacement
D3356
100 350pulpal regeneration - completion of treatment
D3357
150 420apicoectomy - anteriorD3410
150 495apicoectomy - bicuspid (first root)D3421
150 550apicoectomy - molar (first root)D3425
100 310apicoectomy (each additional root)D3426
150 420periradicular surgery without apicoectomyD3427
80 220retrograde filling - per rootD3430
150 330root amputation - per rootD3450
200 330hemisection (including any root removal), not including root canal therapy
D3920
55 175canal preparation and fitting of preformed dowel or post
D3950
Periodontics
120 280gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4210
50 100gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4211
50 100gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4212
250 350anatomical crown exposure - four or more contiguous teeth per quadrant
D4230
200 300anatomical crown exposure - one to three teeth per quadrant
D4231
250 350gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant
D4240
200 200gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant
D4241
200 400apically positioned flapD4245
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
250 320clinical crown lengthening – hard tissueD4249
300 500osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant
D4260
200 350osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant
D4261
215 300bone replacement graft - first site in quadrant
D4263
120 200bone replacement graft - each additional site in quadrant
D4264
230 275guided tissue regeneration - resorbable barrier, per site
D4266
325 350guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)
D4267
400 450surgical revision procedure, per toothD4268
400 450pedicle soft tissue graft procedureD4270
350 350distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)
D4274
400 520free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft
D4277
100 125free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site
D4278
200 240provisional splinting - intracoronalD4320
200 240provisional splinting - extracoronalD4321
45 110periodontal scaling and root planing - four or more teeth per quadrant
D4341
30 90periodontal scaling and root planing - one to three teeth per quadrant
D4342
45 100full mouth debridement to enable comprehensive evaluation and diagnosis
D4355
50 50localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4381
45 80periodontal maintenance (limited to 1 per 6 months & additional at higher copayments)
D4910
125 NCPeriodontal maintenance (additional beyond 1 in 6 months)
D4910
25 25gingival irrigation – per quadrantD4921
Dentures
Dentures and partials include four months free adjustments. Add lab cost of any gold.
310 NCcomplete denture - maxillaryD5110
310 NCcomplete denture - mandibular D5120
320 NCimmediate denture - maxillaryD5130
320 NCimmediate denture - mandibularD5140
180 NCmaxillary partial denture - resin base (including any conventional clasps, rests and teeth)
D5211
180 NCmandibular partial denture - resin base (including any conventional clasps, rests and teeth)
D5212
410 NCmaxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
D5213
410 NCmandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
D5214
610 NCmaxillary partial denture - flexible base (including any clasps, rests and teeth)
D5225
610 NCmandibular partial denture - flexible base (including any clasps, rests and teeth)
D5226
130 NCremovable unilateral partial denture - one piece cast metal (including clasps and teeth)
D5281
Denture Adjustments & Repairs
0 NCadjust complete denture - maxillaryD5410
0 NCadjust complete denture - mandibularD5411
0 NCadjust partial denture - maxillaryD5421
0 NCadjust partial denture - mandibularD5422
30 NCrepair broken complete denture baseD5510
20 NCreplace missing or broken teeth - complete denture (each tooth)
D5520
30 NCrepair resin denture baseD5610
50 NCrepair cast frameworkD5620
40 NCrepair or replace broken claspD5630
20 NCreplace broken teeth - per toothD5640
20 NCadd tooth to existing partial dentureD5650
30 NCadd clasp to existing partial dentureD5660
220 NCreplace all teeth and acrylic on cast metal framework (maxillary)
D5670
220 NCreplace all teeth and acrylic on cast metal framework (mandibular)
D5671
120 NCrebase complete maxillary dentureD5710
120 NCrebase complete mandibular dentureD5711
120 NCrebase maxillary partial dentureD5720
120 NCrebase mandibular partial dentureD5721
60 NCreline complete maxillary denture (chairside)
D5730
60 NCreline complete mandibular denture (chairside)
D5731
60 NCreline maxillary partial denture (chairside)D5740
60 NCreline mandibular partial denture (chairside)
D5741
90 NCreline complete maxillary denture (laboratory)
D5750
90 NCreline complete mandibular denture (laboratory)
D5751
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
90 NCreline maxillary partial denture (laboratory)
D5760
90 NCreline mandibular partial denture (laboratory)
D5761
100 NCinterim complete denture (maxillary)D5810
100 NCinterim complete denture (mandibular)D5811
100 NCinterim partial denture (maxillary)D5820
100 NCinterim partial denture (mandibular)D5821
25 NCtissue conditioning, maxillaryD5850
25 NCtissue conditioning, mandibularD5851
260 NCoverdenture – complete maxillaryD5863
260 NCoverdenture – partial maxillaryD5864
260 NCoverdenture – complete mandibularD5865
260 NCoverdenture – partial mandibularD5866
Implants
*Additional charges of $125 for noble metal, $150 for high noble metal. Add $100 for porcelain on molars, $50 for porcelain butt margin, $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc. Copayments only apply when implant is performed by a participating general dentist.
1500 NCsurgical placement of implant body: endosteal implant
D6010
200 NCsecond stage implant surgeryD6011
200 NCinterim abutmentD6051
200 NCsemi-precision attachment abutmentD6052
450 NCprefabricated abutment – includes modification and placement
D6056
450 NCcustom fabricated abutment – includes placement
D6057
1000 NCabutment supported porcelain/ceramic crown
D6058
1000 NCabutment supported porcelain fused to metal crown (high noble metal)
*D6059
1000 NCabutment supported porcelain fused to metal crown (predominantly base metal)
D6060
1000 NCabutment supported porcelain fused to metal crown (noble metal)
*D6061
1000 NCabutment supported cast metal crown (high noble metal)
*D6062
1000 NCabutment supported cast metal crown (predominantly base metal)
D6063
1000 NCabutment supported cast metal crown (noble metal)
*D6064
1000 NCimplant supported porcelain/ceramic crown
D6065
1000 NCimplant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
*D6066
1000 NCimplant supported metal crown (titanium, titanium alloy, high noble metal)
*D6067
1000 NCabutment supported retainer for porcelain/ceramic FPD
D6068
1000 NCabutment supported retainer for porcelain fused to metal FPD (high noble metal)
*D6069
1000 NCabutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6070
1000 NCabutment supported retainer for porcelain fused to metal FPD (noble metal)
*D6071
1000 NCabutment supported retainer for cast metal FPD (high noble metal)
*D6072
1000 NCabutment supported retainer for cast metal FPD (predominantly base metal)
D6073
1000 NCabutment supported retainer for cast metal FPD (noble metal)
*D6074
1000 NCimplant supported retainer for ceramic FPD
D6075
1000 NCimplant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)
*D6076
1000 NCimplant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
*D6077
30 NCre-cement or re-bond implant/abutment supported crown
D6092
40 NCre-cement or re-bond implant/abutment supported fixed partial denture
D6093
500 NCabutment supported crown - (titanium)*D6094
180 NCbone graft at time of implant placementD6104
2300 NCimplant /abutment supported removable denture for edentulous arch – maxillary
D6110
2300 NCimplant /abutment supported removable denture for edentulous arch – mandibular
D6111
2300 NCimplant /abutment supported removable denture for partially edentulous arch – maxillary
D6112
2300 NCimplant /abutment supported removable denture for partially edentulous arch – mandibular
D6113
500 NCabutment supported retainer crown for FPD (titanium)
*D6194
Bridges
*Additional charges of $125 for noble metal, $150 for high noble metal. Add $100 for porcelain on molars, $50 for porcelain butt margin, $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc.
120 NCpontic - indirect resin based compositeD6205
225 NCpontic - cast high noble metal*D6210
225 NCpontic - cast predominantly base metalD6211
225 NCpontic - cast noble metal*D6212
225 NCpontic - titanium*D6214
240 NCpontic - porcelain fused to high noble metal
*D6240
240 NCpontic - porcelain fused to predominantly base metal
D6241
240 NCpontic - porcelain fused to noble metal*D6242
240 NCpontic - porcelain/ceramic D6245
120 NCpontic - resin with high noble metal*D6250
120 NCpontic - resin with predominantly base metal
D6251
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
120 NCpontic - resin with noble metal*D6252
200 NCprovisional pontic - further treatment or completion of diagnosis necessary prior to final impression
D6253
170 NCretainer - cast metal for resin bonded fixed prosthesis
D6545
170 NCretainer - porcelain/ceramic for resin bonded fixed prosthesis
D6548
170 NCresin retainer – for resin bonded fixed prosthesis
D6549
240 NCinlay - porcelain/ceramic, two surfaces D6600
240 NCinlay - porcelain/ceramic, three or more surfaces
D6601
230 NCinlay - cast high noble metal, two surfaces*D6602
230 NCinlay - cast high noble metal, three or more surfaces
*D6603
230 NCinlay - cast predominantly base metal, two surfaces
D6604
230 NCinlay - cast predominantly base metal, three or more surfaces
D6605
230 NCinlay - cast noble metal, two surfaces*D6606
230 NCinlay - cast noble metal, three or more surfaces
*D6607
230 NConlay - porcelain/ceramic, two surfacesD6608
230 NConlay - porcelain/ceramic, three or more surfaces
D6609
230 NConlay - cast high noble metal, two surfaces
*D6610
230 NConlay - cast high noble metal, three or more surfaces
*D6611
230 NConlay - cast predominantly base metal, two surfaces
D6612
230 NConlay - cast predominantly base metal, three or more surfaces
D6613
230 NConlay - cast noble metal, two surfaces*D6614
230 NConlay - cast noble metal, three or more surfaces
*D6615
225 NCinlay - titanium*D6624
225 NConlay - titanium*D6634
120 NCcrown - indirect resin based composite D6710
120 NCcrown - resin with high noble metal*D6720
120 NCcrown - resin with predominantly base metal
D6721
120 NCcrown - resin with noble metal*D6722
230 NCcrown - porcelain/ceramicD6740
240 NCcrown - porcelain fused to high noble metal
*D6750
240 NCcrown - porcelain fused to predominantly base metal
D6751
240 NCcrown - porcelain fused to noble metal*D6752
225 NCcrown - 3/4 cast high noble metal*D6780
225 NCcrown - 3/4 cast predominantly base metal
D6781
225 NCcrown - 3/4 cast noble metal*D6782
250 NCcrown - 3/4 porcelain/ceramicD6783
225 NCcrown - full cast high noble metal*D6790
225 NCcrown - full cast predominantly base metal
D6791
225 NCcrown - full cast noble metal*D6792
200 NCprovisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression
D6793
225 NCcrown - titanium*D6794
20 NCre-cement or re-bond fixed partial denture
D6930
Oral Surgery
0 65extraction, coronal remnants - deciduous tooth
D7111
0 70extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7140
30 150surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
D7210
50 150removal of impacted tooth - soft tissueD7220
75 215removal of impacted tooth - partially bony
D7230
100 265removal of impacted tooth - completely bony
D7240
275 275removal of impacted tooth - completely bony, with unusual surgical complications
D7241
120 222surgical removal of residual tooth roots (cutting procedure)
D7250
100 265coronectomy – intentional partial tooth removal
D7251
200 300tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7270
150 265surgical access of an unerupted toothD7280
200 300mobilization of erupted or malpositioned tooth to aid eruption
D7282
75 95incisional biopsy of oral tissue-hard (bone, tooth)
D7285
75 95incisional biopsy of oral tissue-softD7286
30 60brush biopsy - transepithelial sample collection
D7288
55 160alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7310
55 140alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7311
55 240alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7320
55 140alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7321
150 300removal of lateral exostosis (maxilla or mandible)
D7471
5 100incision and drainage of abscess - intraoral soft tissue
D7510
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Code Description Copayment
Dentist Specialist
Code Description Copayment
Dentist Specialist
100 150incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
D7511
150 200frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure
D7960
175 225frenuloplastyD7963
175 250excision of hyperplastic tissue - per archD7970
40 70excision of pericoronal gingiva D7971
Other Services
10 100palliative (emergency) treatment of dental pain - minor procedure
D9110
40 NCfixed partial denture sectioningD9120
0 0local anesthesia not in conjunction with operative or surgical procedures
D9210
0 0regional block anesthesiaD9211
0 0trigeminal division block anesthesiaD9212
0 0local anesthesia in conjunction with operative or surgical procedures
D9215
0 0consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician
D9310
0 5office visit for observation (during regularly scheduled hours) - no other services performed
D9430
50 NCoffice visit - after regularly scheduled hours
D9440
0 NCcase presentation, detailed and extensive treatment planning
D9450
15 NCtherapeutic parenteral drug, single administration
D9610
30 NCtherapeutic parenteral drugs, two or more administrations, different medications
D9612
25 25other drugs and/or medicaments, by report
D9630
20 NCapplication of desensitizing medicamentD9910
20 NCapplication of desensitizing resin for cervical and/or root surface, per tooth
D9911
25 NCcleaning and inspection of a removable appliance
D9931
180 NCocclusal guard, by reportD9940
100 NCfabrication of athletic mouthguardD9941
90 NCrepair and/or reline of occlusal guardD9942
35 80occlusal adjustment - limitedD9951
75 150occlusal adjustment - completeD9952
20 NCenamel microabrasion D9970
20 NCodontoplasty 1 - 2 teeth; includes removal of enamel projections
D9971
200 NCexternal bleaching - per arch - performed in office
D9972
100 NCexternal bleaching - per toothD9973
100 NCinternal bleaching - per toothD9974
200 NCexternal bleaching for home application, per arch; includes materials and fabrication of custom trays
D9975
Orthodontics
25Consultation
25Failed/no-show appointment without 24-hour notice
1975Full banded - child, up to age 19
2175Full banded - adult
1250Partial banded - child, up to age 19
1550Partial banded - adult
600Mixed dentition - phase 1
450Palatal expansion
600Rapid palatal expansion
250Retention appliance - after orthodontic treatment
600Functional appliance (Bionator-Frankel)
400Headgear
400Simple crossbite
40Copying records
Please call your Dental Health Services Member Service Specialist at 800-637-6453 for a referral to a conveniently located participating orthodontist. Orthodontic models, x-rays, photographs and records are not covered. There may be additional copayments depending on treatment needs.
Current Dental Terminology © 2014 American Dental Association. All rights reserved0714M157 Effective Date: 1/1/2015
Orthodontic exclusionsThe following services are not covered by your dental plan:
A. Retreatment of orthodontic cases.B. Treatment of a case in progress at inception of eligibility.C. Surgical procedures (including extraction of teeth) incidental
orthodontic treatment.D. Surgical procedures related to cleft palate, micrognathia or
macrognathia.E. Treatment related to temporomandibular joint (TMJ) disturbances and/
or hormonal imbalances.F. Anydentalprocedureconsideredwithinthefieldof generaldentistry
including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation dental services of any nature performed in a hospital.
G. Cephalometric x-rays, dental x-rays.H. Tracings and photographs.I. Study models.J. Replacement of lost or broken appliances.K. Changes in treatment necessitated by an accident of any kind.L. Services which are compensable under worker’s compensation or
employer liability laws.M. Malocclusions so severe or mutilated they are not amenable to ideal
orthodontic therapy.
Orthodontic limitationsThe following are subject to additional charges:
A. Full banded treatments are based on a 24-month standard treatment plan. Additional treatment, or treatment that extends beyond that time may be subject to additional charges.
B. If the member should terminate coverage, they are no longer eligible for the plan’s orthodontic rate.C. Should the contract between Dental Health Services and the orthodontist terminate, any Dental Health Services members in treatment would not be subject to proration.
Dental exclusionsThe following services are not covered by your dental plan:
A. Services that are not consistent with professionally recognized standards of practice.
B. Cosmeticservices,forappearanceonly,unlessspecificallylisted.C. Myofunctional therapy-procedures for training, treating or developing
muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard.
D. Treatment for malignancies, neoplasms (tumors) and cysts as well as hereditary, congenital and/or developmental malformations.
E. Dispensingof drugsnotnormallysuppliedinadentaloffice.F. Hospitalization charges, dental procedures or services rendered while
patient is hospitalized.G. Procedures,appliancesorrestorations(otherthanfillings)thatare
necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 10 crowns/ pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion.
H. Procedures performed by a prosthodontist.
Exclusions and Limitations of CoverageSuper SmartSmileSM Plan
© 2014 Dental Health Services. All rights reserved.
I. Fixed bridges for patients under the age of sixteen, in the presence of non-supportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth
in an arch, replacement of missing third molars, or when the prognosis is poor.
J. General anesthesia, including intravenous and inhalation sedation.K. Dentalproceduresthatcannotbeperformedinthedentalofficedueto
the general health and/or physical limitations of the member.L. Expenses incurred for dental procedures initiated prior to member’s
eligibility with Dental Health Services, or after termination of eligibility.M. Services that are reimbursed by a third party (such as the medical
portion of an insurance/health plan or any other third party indemnification).
N. Extractions of non-pathologic, asymptomatic teeth, including extractions and/or surgical procedures for orthodontic reasons.
O. Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures.
P. Coordinationof benefitswithanotherprepaidmanagedcaredentalplan.
Q. Orthodontic treatment of a case in progress and/or retreatment of ortho cases.
R. Cephalometric x-rays, tracings, photographs and orthodontic study models.
S. Replacement of lost or broken orthodontic appliances.T. Changes in orthodontic treatment necessitated by an accident of any kind.U. Malocclusions so severe or mutilated which are not amenable to ideal
orthodontic therapy.V. ServicesnotspecificallylistedontheScheduleof CoveredServicesand
Copayments.
Dental limitationsRestrictions on benefits are applied to the following services:
A. Treatment of dental emergencies is limited to treatment that will alleviateacutesymptomsanddoesnotcoverdefinitiverestorative treatment including, but not limited to root canal treatment and crowns.
B. Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient.
C. Routine teeth cleaning (prophylaxis) is limited to once every six months and full mouth x-rays are limited to one set every three years if needed.
D. Specialty referrals must be pre-approved by Dental Health Services for any treatment deemed necessary by the treating participating dentist.
E. Pre-authorization is required for all specialty services, with the exception of orthodontics.F. Periodontal surgical procedures are limited to four quadrants every two
years.G. There are additional charges for precious/noble metals (gold).H. Replacement will be made of any existing appliance (denture, etc.) only
if it is unsatisfactory and cannot be made satisfactory. Prosthetic applianceswillbereplacedonlyafterfiveyearshaveelapsedfromthetime of delivery. Lost or stolen removable appliances are the responsibility of the enrollee.
I. Relines are limited to once per twelve months, per appliance.J. Singleunitinlaysandcrownsareabenefitasprovidedaboveonlywhen
the teeth cannot be adequately restored with other restorative materials.K. Themaximumbenefitforpedodonticspecialtycareis$500perlifetime.L. Thereisa$1,000maximumbenefitpermember,percontractyear,
excluding orthodontics.
Professional services - specialty services: Copayments vary by procedure andappear in the enclosed Schedule of Covered Services and Copayments. There isa$1,000maximumbenefitpermember,percontractyear,excludingorthodontics.
Outpatientofficevisits:$4
Hospitalization services: Not covered
Prescription drug coverage: Not covered
Emergency health services: Not covered
Ambulance services: Not covered
Durable medical equipment: Not covered
Mental health services: Not covered
Chemical dependency services: Not covered
Home health services: Not covered
Health plan benefits and coverage matrix
Thismatrixisintendedtobeusedtohelpyoucomparecoveragebenefitsand is a summary only. The evidence of coverage and plan contract should beconsultedforadetaileddescriptionof coveragebenefitsandlimitations.
Deductibles: None
Lifetime maximums:Themaximumbenefitforpedodonticspecialtycareis$500perlifetime.Therearenoothermaximums.
Professional services - exam & preventive services: No charge for most services. Full mouth x-rays limited to every three years. Prophylaxis (cleanings) limited to every six months.
Professional services - restorative, crowns, endodontics and oral surgery services:Copaymentsforfillings,caps,rootcanalsandextractionsvarybyprocedure in the enclosed Schedule of Covered Services and Copayments.
Professional services - periodontic services: Copayments for gum treatments vary by procedure in the enclosed Schedule of Covered Services and Copayments. Surgical procedures are limited to four quads every two years.
Professional services - dentures and partial dentures: Copayments vary by procedure and appear in the enclosed Schedule of Covered Services and Copayments.Replacementslimitedtoeveryfiveyears.Relineslimitedtoevery 12 months.
Dental Health ServicesA Great Reason to Smile sm
3833 Atlantic Avenue, Long Beach, CA 90807800-637-6453 | www.dentalhealthservices.com
© 2012 Dental Health Services
0314M017 © 2014 Dental Health Services
Combined Evidence of Coverage & Disclosure
SmartSmilesm & Super SmartSmilesm
A Great Reason to Smilesm
Mission Statement
To consistently deliver high quality, affordable, value-driven dental service through a caring staff
and an accountable provider network committed to member satisfaction.
Dental Health Services
EnglishIMPORTANT: Can you read this? If not, we can have someone help you read it. You may also be able to get this information written in your language. For free help, please call right away at 1-866-756-4259. Dental Health Services has a toll free TTY line 1-888-645-1257 for the hearing and speech impaired.
SpanishIMPORTANTE: ¿Puedes leer esto? Si no, alguien le puede ayudar a leerla. Además, es posible que re-ciba esta información escrita en su propio idioma. Para obtener ayuda gratuita, llame ahora mismo al 1-866-756-4259. Dental Health Services también tiene una línea TTY 1-888-645-1257 para personas con dificultades de audición o de hablar.
Table of contents
Welcome to Dental Health Services ................1Your Prepaid Dental Plan .................................1Definitions ...........................................................2Eligibility ..............................................................3Beginning Coverage ...........................................4Choosing Your Dentist .....................................5Making an Appointment ...................................5Facilities ...............................................................6Changing Dentists ..............................................6Treatment Authorization ..................................6Emergency Care: In-Area .................................7Emergency Care: Out-of-Area .........................7Copayments.........................................................8Quality Assurance ..............................................8Liability of Subscriber for Payment ................8Optional Treatment ...........................................9Second Opinions ................................................9Continuity of Care .............................................9Termination of Benefits .................................11Termination Due to Nonpayment.................12Review of Termination ...................................12Cancellation Policy ...........................................12Member Services ..............................................13Grievance Procedure .......................................14Confidentiality and Privacy Notice ................15Public Policy Committee .................................23Organ Donation ...............................................23
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Welcome to Dental Health Services We are glad to have you as a valued member of our special dental care organization. You are important to us, and so is your healthy smile. We want to keep you smiling by helping you protect your teeth, sav-ing you time and saving you money. As a member of Dental Health Services, you and your family are entitled to some important and valuable benefits.
Your Evidence of Coverage and Disclosure Form (“EOC”) discloses the terms and conditions of coverage. You have a right to view this EOC prior to enrollment. Your EOC should be read com-pletely, and individuals with special dental care needs should read carefully those sections that apply to them. If you have questions or would like to obtain copies of your enrollment form/plan contract, please contact Dental Health Services at 800-637-6453 to speak to your Member Service Specialist. You may also write to Member Services, Dental Health Services, 3833 Atlantic Avenue, Long Beach, CA 90807.
You will find your Health Plan Benefits and Cover-age Matrix on the enclosed Schedule of Covered Services and Copayments.
Your Prepaid Dental PlanDental Health Services offers you a prepaid, direct service dental care program. Your specialized den-tal plan has been designed to provide the maximum benefits at low cost to you and your family. Conve-nience of location, availability of services (many at no cost to you), and a minimum of paperwork make it easy to receive quality dental care. Your plan offers:
• Your choice of dental offices within the Dental Health Services network
• Unlimited number of visits• No claim forms
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• No “deductible” costs• Professional service in a friendly
atmosphere• Conveniently located dental offices• Specialist referral system DefinitionsAcute condition: a medical condition that involves a sudden onset of symptoms due to an illness, inju-ry, or other medical problem that requires prompt medical attention and that has a limited duration.
Copayment: the fee paid by a member to a Den-tal Health Services dentist for covered office visit and/or services as disclosed in the Schedule of Covered Services and Copayments.
Designated dental center: the office and facili-ties of the specific Dental Health Services dentist selected by you to provide covered services.
Dental Health Services dentist (participating dentist): a licensed dentist who contracts with Dental Health Services to provide covered services to enrollees.
Domestic partners: two adults who have chosen to share one another’s lives in an intimate and com-mitted relationship of mutual caring and who file a Declaration of Domestic Partnership with the Secretary of State.
Emergency dental condition: a dental condi-tion manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the fol-lowing: (1) placing the patient’s dental health in serious jeopardy, (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily
3
organ or part.
Exclusion: any provision in the agreement where-by coverage for a specified procedure or condition is entirely eliminated.
Limitation: any provision in this agreement that restricts coverage.
Member or enrollee: a person who is entitled to receive dental care services under this agreement. The term includes both subscribers and those family members for whom a subscriber has paid a premium.
Serious chronic condition: a medical condition due to a disease, illness, or other medical prob-lem or medical disorder that is serious in nature, and persists without full cure or worsens over an extended period of time, or requires ongoing treat-ment to maintain remission or prevent deteriora-tion.
Specialty services: dental services provided by a Dental Health Services contracted or authorized dental specialist (endodontist, periodontist, pedo-dontist, oral surgeon, or orthodontist). All referrals for covered specialty services must be pre-autho-rized by Dental Health Services.
Subscriber: the person who signs the enrollment card or application, and represents their family for dental coverage under this agreement.
EligibilityAs the subscriber, you may enroll yourself, your spouse or your domestic partner (unless legally separated), and/or dependent children who are under 26 years of age.
Children 26 years of age and over are eligible if the
4
child is and continues to be both (1) incapable of self-sustaining employment by reason of a men-tal disability, including, but not limited to, mental illness or physical disability or a combination of those disabilities and (2) chiefly dependent upon the subscriber or member for support and mainte-nance.
For disabled dependents, Dental Health Services will provide notice to the subscriber at least 90 days prior to the date the child attains limiting age.
Dental Health Services may require proof of the above, which the subscriber must furnish within 60 days of such a request. Failure to do so may result in termination of your child’s eligibility.
Beginning CoverageComplete your enrollment card when you become eligible. Newly acquired dependents become eli-gible immediately, but they must be enrolled within 30 days of acquisition. Newborn children are covered from birth, but must be enrolled within 30 days of birth to continue coverage.
If your eligibility is approved by the 20th of the month, coverage begins on the first day of the fol-lowing month. If your eligibility is approved after the 20th of the month, coverage begins on the first day of the sec-ond month following eligibility approval.
If you are in the middle of acute dental care when your coverage begins, please contact your Mem-ber Service Specialist at 800-637-6453 to assure continuity of care. You may also request a copy of the Dental Health Services policy describing the process for continuity of care, including review of request to continue care with your existing dentist.
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Choosing Your DentistPLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF DENTISTS HEALTH CARE MAY BE OBTAINED.
Covered services are only provided by dentists who are contracted with Dental Health Services. Simply select a dental office from your Directory of Par-ticipating Dentists and include the information on your enrollment card. If you did not select a dentist when you enrolled, a dentist may be selected for you. Please call your Member Service Specialist at 800-637-6453.
Our dentists are compensated by copayments and/or supplemental payments based on procedures completed. Except for shared risk arrangements involving specialty services, financial bonuses or incentives for performing or withholding profes-sionally approved services are not used. If you wish to know more about these issues, you may request additional information from your Member Service Specialist or your Dental Health Services dentist.
Making an AppointmentYou may make an appointment with your selected dentist as soon as you receive confirmation of your eligibility. For your convenience, call your dental office directly to schedule appointments. Routine appointments will be scheduled within a reasonable time. Your plan covers care provided only by your selected dentist, except in case of an out-of- area emergency. All referrals for specialist services must be pre-authorized by Dental Health Services. Treat-ment is approved and rendered by the dental office according to plan benefits. If treatment authori-zation is denied, you may contact Dental Health Services (see Grievance procedure).
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FacilitiesEach dental office establishes its own policies, procedures and hours. Directories of Participating Dentists are available directly from your Member Service Specialist.
Changing DentistsIf you wish to change your dentist, simply contact your Member Service Specialist by the 10th of the current month to become eligible with your new office as of the 1st of the following month. Changes called in after the 10th of the month will be effective as of the 1st of the second month.
If a covered family member wishes to receive care from a Dental Health Services dentist different than yours, please call your Member Service Spe-cialist about our split-facility option.
Treatment AuthorizationDental Health Services works closely with our providers to authorize or deny dental services, to provide the best care available, and to protect our members. Authorization and utilization manage-ment specialists verify eligibility, authorize services, and facilitate the delivery of dental care to mem-bers. Services are authorized based on the ben-efits, limitations, and exclusions listed in each plan Evidence of Coverage.
Specialty services, if covered by your plan, require prior authorization by Dental Health Services. If you have questions, wish to appeal a denial or would like to obtain copies of Dental Health Services’ Treatment Authorization and Utilization Management Procedures (the process the Plan uses to authorize or deny health care services), please contact Dental Health Services to speak to your Member Service Specialist.
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Emergency Care: In-AreaPalliative (pain relief) care for emergency dental conditions (see Emergency Dental Condition under Definitions) such as acute pain, bleeding, or swelling is a benefit according to your Schedule of Covered Services and Copayments.
If you have a dental emergency and need to seek immediate care, first call your Dental Health Ser-vices dentist. Participating dental offices maintain 24 hour emergency communication accessibility and are expected to see you within 24 hours of contacting the dental office or within such lesser time as may be medically indicated. If your dentist is not available, call your Member Service Special-ist. If both the dental office and Dental Health Services cannot be reached, you are covered for emergency care at another participating dentist, or from any dentist. You will be reimbursed for the cost of emergency palliative treatment less any copayments that apply. Contact your assigned pro-vider for follow-up care as soon as possible.
If you have a medical emergency, you should get care immediately by calling 911 or going to the nearest hospital emergency room.
Emergency Care: Out-of-AreaOut-of-area emergency care is emergency pallia-tive dental treatment required while an enrollee is anywhere outside of Dental Health Services’ service area. Your benefit includes up to $50.00 per enrollee per incident, after copayments are deduct-ed. You must submit an itemized receipt from the dental office that provided the emergency service with a brief explanation, and your subscriber ID number, to Dental Health Services within 180 days. After 180 days, Dental Health Services reserves the right to refuse payment.
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CopaymentsCopayments are your portion of office visit and/or services as disclosed in this Evidence of Coverage. You are responsible for the copayments for ser-vices provided to you and your family. Copayments are payable directly to the dentist when the service is rendered (unless other arrangements are made).
Quality AssuranceWe’re confident about the care you’ll receive because our dentists meet and exceed the high-est standards of care, standards demanded by our Quality Assurance program. Before we contract with our dentists, we visit their offices to make sure your needs will be met. Dental Health Services’ Professional Services Representatives regularly meet and work with our dentists to maintain excel-lence in dental care. Liability of Subscriber for Payment You are not liable for any sums owed by Dental Health Services to a participating dentist. You will be liable for the cost of non-covered services performed by a participating dentist and for any services performed by a non-participating dentist that Dental Health Services does not pre-approve or pay.
IMPORTANT: If you opt to receive dental ser-vices that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that in-cludes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage op-tions, you may call member services at 800-637-6453 or your insurance broker. To fully understand
9
your coverage, you may wish to carefully review this evidence of coverage document.
Optional TreatmentIf you choose a more expensive elective treatment in lieu of a covered benefit, the elective treatment is considered optional. You are responsible for the cost difference between the covered and optional treatment on a fee-for-service basis. If you have any questions about optional treatment or services you are asked to pay additional for, please contact your Member Service Specialist before you begin services or sign any agreements.
Second OpinionsSecond dental opinions are a covered benefit. Please contact your Member Service Specialist if you wish to arrange for a second dental opinion. Appointment arrangement will be made within five days for routine second opinions, within 72 hours for serious conditions, and immediately for emer-gencies.
Continuity of CareIf you are currently in the middle of treatment with your current participating dentist, you may have a right to keep your current dentist for a des-ignated time period. Please contact your Member Service Specialist at 800-637-6453 or through www.dentalhealthservices.com to request assistance or to obtain a copy of Dental Health Services’ Con-tinuity of Care Policy describing the process for continuation of care.
You may qualify for and request continuation of covered services for certain qualifying conditions from your current dentist. Dental Health Services, at the request of an enrollee, will provide the completion of covered services for treatment of certain specified conditions if the services were
10
being provided by a dental office that is no longer affiliated with Dental Health Services at the time of termination of the dentist’s contract, or if the covered services were being provided by a non-participating dentist to a newly covered enrollee at the time his or her coverage became effective. This policy does not apply to a newly covered enrollee covered under an individual subscriber agreement.
The enrollee has a right to complete covered ser-vices with their non-participating dentist if they fall within one of the categories listed below:
• Completion of covered services shall be pro-vided for the duration of an acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and has a limited duration.
• Completion of covered services for an en-rollee newborn child between birth and age 36 months, not to exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly cov-ered enrollee.
• Performance of a surgical or other procedure that is authorized by the plan as a part of a documented course of treatment and has been recommended and documented by the dentist to occur within 180 days of the dentist’s con-tract termination for current enrollees or 180 days from the effective date of coverage for newly covered enrollees.
All services are subject to Dental Health Services’ consent and approval, and approval by the termi-nated dentist, consistent with good professional practice. You must make a specific request to
11
continue under the care of your current dentist. Dental Health Services is not required to continue your care with the dentist if you are not eligible under our policy or if we cannot reach agreement with the dentist on the terms regarding your care in accordance with California law. Your request must be made within 30 days of the dentist’s termina-tion. If a good cause exists, an exception to the 30-day time limit will be considered. If you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its toll-free number 888-HMO-2219, at a TDD number for the hearing impaired at 877-688-9891, or online at www.hmohelp.ca.gov.
Termination of BenefitsCoverage of an individual member may be termi-nated for any of the following reasons:
• Failure of a member to meet the eligibility requirements;
• Material misrepresentation (fraud) in obtaining coverage;
• Failure of the subscriber to pay applicable copayments when due;
• Actions of member substantially impair the Plan’s or dentist’s ability to provide services;
• Permitting the use of a Dental Health Services membership card by another person, or using another person’s membership card to obtain care to which one is not entitled;
• Failure of the member to pay premium in a timely manner;
• Course of conduct exhibiting use or threat of
12
violent actions, or profane, abusive or threaten-ing language.
Coverage for a subscriber and his/her dependents will terminate at the end of the month during which the subscriber ceases to be eligible for cover-age, except for any of the reasons above, when ter-mination may be mid-month. Notice will be given by Dental Health Services to the subscriber at least 15 days prior to canceling the coverage. Termination Due to Nonpayment Benefits under this plan depend on premium pay-ments being current. Enrollment will be cancelled on the date, time or occurrence specified in the Notice of Cancellation to enrollee, but not sooner than expiration of 15 days following such notice. Any service(s) then “in progress” will be completed within 30 days with the member’s cooperation. Member will remain liable for the scheduled copay-ment, if any. We encourage you to make individual arrangements with your dentist for continuing the diagnosed services if your benefits are terminated.
Review of TerminationIf you believe your membership was terminated by Dental Health Services because of ill health or your need for care, you may request a review of the termination from Dental Health Services’ corpo-rate office. You may also request a review from the Department of Managed Health Care.
Cancellation PolicyIf you cancel your plan prior to your first year renewal period, you will be subject to a $35.00 cancellation fee to cover the administrative costs of the cancellation process. Any unearned premiums, less any cancellation fees, will be refunded within 30 days.
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If you wish to cancel your dental benefits, please contact us at 800-637-6453. Cancellation requests must be received in writing and must be signed by the subscriber. Cancellation requests received by the 15th of the month will be effective the first of the following month.
Member ServicesDental Health Services is dedicated to assuring your satisfaction and is committed to keeping your plan as simple and clear as possible. As employee-owners, we have a vested interest in the well being of our plan members. Part of our dedication to serving you includes easy, toll-free access to your knowledgeable Member Service Specialist to help answer any of your questions about your plan and coverage. Please feel free to call or write us with any questions or comments you might have. We will do everything possible to help you. Your Mem-ber Service Specialist can be reached at:
Dental Health ServicesMember Services Department3833 Atlantic AvenueLong Beach, CA 90807-3505800-637-6453
The majority of inquiries can and will be respond-ed to immediately, including those regarding and affecting emergency services. Should Dental Health Services need to acquire additional information, a decision regarding urgent care will be made within 72 hours and decisions affecting routine services are made within five business days. When Dental Health Services is unable to receive all the informa-tion necessary for a decision, the member and the dentist are notified within five business days of the progress.
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Grievance ProcedureYou should, but it is not required, first discuss any grievance regarding treatment or treatment costs with your dentist. For assistance you may contact your Member Service Specialist by calling 800-637-6453, mailing a letter to Member Services, Den-tal Health Services, 3833 Atlantic Avenue, Long Beach, CA 90807, or by submitting electronically at www.dentalhealthservices.com.
Dental Health Services will resolve the grievances, including all levels of appeal, within 30 days of receiving the grievance or notification. Grievances involving emergency care are addressed immedi-ately and responded to in writing within three days. Should you be unhappy with the decision, you may request a review by notifying Dental Health Ser-vices in writing. Voluntary mediation is available by submitting a request to Dental Health Services.
The following is the exact language and notice as required by the DMHC (Department of Man-aged Health Care) and it is important to note that, although this refers to “Health Plans,” it also includes your dental plan. We are here to help you. Please contact us and allow one of our Member Service Specialists to assist you.
"The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 800-637-6453 and use your health plan’s grievance process before contacting the depart-ment. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained a grievance that has remained unresolved for more than 30
15
days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll- free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online." For additional information, please contact your Member Service Specialist.
Confidentiality and Privacy Notice Dental Health Services is committed to protecting your privacy and the confidentiality of your dental, medical, and protected health information (PHI) that we may obtain or to which we have access. We do not sell our client information. Your personal information will not be disclosed to non-affiliated third parties unless permitted or required by law, or authorized in writing by you.
Throughout this Notice, unless otherwise stated, your medical and dental health information refers to only health information created or received by Dental Health Services and identified in this Notice as Protected Health Information (PHI). Please note that your dentist maintains your dental records, including payments and charges. Dental Health Services will have a record of this portion of your PHI only in special or exceptional cases.
Dental Health Services’ privacy policies describe who has access to your PHI, how it will be used,
16
when your PHI may be disclosed, safeguards to protect the privacy of your PHI and the training we provide our employees regarding maintaining and protecting your privacy. Under what circumstances must Dental Health Services share my PHI?
Dental Health Services is required to disclose your PHI to you, and to the U.S. Department of Health and Human Services (HHS) when it is conducting an investigation of compliance with legal require-ments. Dental Health Services is also required to disclose your PHI, subject to certain requirements and limitations, if the disclosure is compelled by (any of the following):
A. A court order.B. A board, commission or administrative
agency, pursuant to its lawful authority.C. A party to a proceeding pursuant to a
subpoena, subpoena duces tecum, or other authorized discovery in a proceeding before a court or an administrative agency.
D. An arbitrator or panel of arbitrators in a law fully- requested arbitration.
E. A search warrant.F. A coroner in the course of an investigation. G. By other law.
When may Dental Health Services disclose my PHI without my authorization?
Dental Health Services is permitted by law to use and disclose your PHI, without your authorization, for purposes of payment and health care adminis-tration.
A. Payment purposes include activities to col-lect premiums and to determine or main-tain coverage. These include using PHI in
17
billing and collecting premiums, and related data processing including how your dentist obtains pre-authorization for certain den-tal services. For example, Dental Health Services periodically conducts quality assur-ance inspections of your dentist’s office and during such visits may review your dental records as part of this audit.
B. Health Care Administration means basic activities essential to Dental Health Servic-es’ function as a licensed limited healthcare service contractor, and includes reviewing the qualifications and competence of your dentist; evaluating the quality of his/her services; providing subscriber services and information including answering enrollee inquiries but without disclosing PHI. Dental Health Services may, for example, review your dentist’s records to determine if the copayments being charged by the office comply with the contract under which you receive dental coverage.
C. In addition, Dental Health Services is permitted to use and disclose your PHI, without your authorization, in a variety of other situations, each subject to limitations imposed by law. These situations include, but are not limited to, the following uses and disclosures:
1. Public health activities.2. Concerning victims of abuse, neglect or
domestic violence.3. Health oversight agency.4. Judicial and administrative proceedings
including the defense by Dental Health Services of a legal action or proceeding brought by you.
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5. Law enforcement purposes, subject to subpoena of law.
6. Workers’ Compensation purposes.7. Parents or guardians of a minor.8. Persons or entities who perform servic-
es on behalf of Dental Health Services and from whom Dental Health Services has received contractual assurances to protect the privacy of your PHI.
Is Dental Health Services ever required to get my permission before sharing my PHI?
Uses and disclosures of PHI other than those re-quired or permitted by law will be made by Dental Health Services only with your written authori-zation. You may revoke any authorization given to Dental Health Services at any time by written notice of revocation to Dental Health Services, ex-cept to the extent that Dental Health Services has relied on the authorization before receiving your written revocation. Uses and disclosures beyond those required or permitted by law, or authorized by you, are prohibited. Does my employer have the right to access my PHI?
If you are an enrollee under a plan sponsored by your employer, Dental Health Services will not disclose PHI to your employer except under the following conditions:
A. You sign an authorization for release of your medical/dental information.
B. Health care services were provided with specific prior written request and expense of the employer, and are relevant in a grievance, arbitration or lawsuit, or describe limitations entitling you to leave from work or limit work
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performance.
Any such disclosure is subject to Dental Health Services’ minimum necessary disclosure policy.
What is Dental Health Services’ minimum necessary disclosure policy?
Dental Health Services uses reasonable efforts to limit the use and disclosure of your PHI to the minimum necessary to accomplish the purpose of the use or disclosure. This restriction includes re-quests for PHI from another entity, and to requests made by Dental Health Services to other entities. This restriction does not apply to requests by:
A. Your dentist for treatment purposes. B. You.C. Disclosures covered by an authorization you
provided to another entity.
What are my rights regarding the privacy of my PHI?
Your rights respecting your PHI, and how you may exercise these rights are summarized here.
A. You may request Dental Health Services to restrict uses and disclosures of your PHI in the performance of its payment or health care operations. However, a written request is required. Your health is the top priority and Dental Health Services is not required to agree to your requested restriction. If Dental Health Services agrees to your requested restriction, the restriction will not apply in situations involving emergency treatment by a health care provider.
B. Dental Health Services will comply with your reasonable request that you wish to receive
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communications of your PHI by alternative means or at alternative locations. Such requests must be made to Dental Health Services in writing.
C. You have a right, subject to certain limitations, to inspect and copy your PHI. Your request must be made in writing. Dental Health Ser-vices will act on such request within 30 days of receipt of request.
D. You have the right to amend your PHI. The request to amend must be made in writing, and must contain the reason you wish to amend your PHI. Dental Health Services has the right to deny such requests under certain condi-tions provided by law. Dental Health Services will respond to your request within 60 days of receipt of the request and, in certain circum-stances may extend this period for up to an additional 30 days.
E. You have the right to receive an accounting of disclosures of your PHI made by Dental Health Services for up to 6 years preceding such request subject to certain exceptions pro-vided by law. These exceptions include, but are not limited to:
1. Disclosures made for payment or health-care operations purposes.
2. Disclosures occurring prior to February 26, 2002.
Your request must be made in writing. Dental Health Services will provide the accounting within 60 days of your request but may extend the period for up to an additional 30 days. The first accounting requested during any 12 month period will be made without charge. There is a $25 charge for each additional accounting
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requested during such 12 month period. You may withdraw or modify any additional re-quests within 30 days of the initial request in order to avoid or reduce the fee.
F. You have the right to receive a copy of this Notice, and any amended Notice, upon written or telephone request made to Dental Health Services.
G. All written requests for the purposes described
in this section, and all other written commu-nications to Dental Health Services desired or required by this Notice, must be delivered to:
Dental Health Services3833 Atlantic AvenueLong Beach, CA 90807
by any of the following means:
1. Personal delivery.2. E-mail delivery to membercare@dental
healthservices.com.3. First class or certified U.S. Mail.4. Overnight or courier delivery, charges pre-
paid.
What duties does Dental Health Services agree to perform?
A. Dental Health Services will maintain the privacy of your PHI and provide you with notice of its legal duties and privacy practices with respect to PHI.
B. Dental Health Services will abide by the terms of this Notice and any revised Notice, during the period that it is in effect.
C. Dental Health Services reserves the right to
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change the terms of this Notice or any revised Notice. Any new terms shall be effective for all PHI that it maintains including PHI created or received by Dental Health Services prior to the effective date of the new terms.
Each time Dental Health Services makes a revised Notice, it shall 1) post it on its website, and 2) dis-tribute a written copy personally by first class U.S. mail to each of its subscribers who are enrolled with Dental Health Services during the period that such revised Notice remains effective.
What if I am dissatisfied with Dental Health Services’ compliance with HIPAA (Health Insurance Portability and Accountability Act) privacy regulations?
You have the right to express your dissatisfaction or objection to:
Dental Health ServicesAttn: Privacy Officer3833 Atlantic AvenueLong Beach, CA 90807
Your written dissatisfaction must describe the acts or omissions you believe to be in violation of the provisions of this Notice or applicable laws. Your written objection to HHS or Dental Health Servic-es must be filed within 180 days of when you knew or should have known of the act or omission. You will not be penalized or retaliated against for com-municating your dissatisfaction.
Who should I contact if I have any questions regarding my privacy rights with Dental Health Services?
You may obtain further information regarding your PHI privacy rights by contacting your Member
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Service Specialist at 800-637-6453 during regular office hours or at www.dentalhealthservices.com.
Public Policy CommitteeAs a member of Dental Health Services, your concerns about benefits and services that Dental Health Services offers are important to us. Dental Health Services’ Public Policy Committee reviews member needs and concerns, and recommends improvements to the Plan. You are invited to participate in the Public Policy Committee. If you are interested in membership on the committee or would like to comment, send your request in writing to the Public Policy Committee Coordina-tor, Dental Health Services, 3833 Atlantic Avenue, Long Beach, CA 90807-3505.
Organ DonationDental Health Services is committed to promot-ing the life-saving practice of organ donation. We encourage all of our members to give the gift of life by choosing to become organ donors. Valu-able information on organ donation and related health issues can be found on the Internet at www. organdonor.gov or visit your local DMV office for a donor card.
Dental Health Services
An Employee-Owned Company
3833 Atlantic AvenueLong Beach, CA 90807
800-637-6453 www.dentalhealthservices.com
© 2013 Dental Health Services
