Sizwe Medical Fund Dental Benefit Table 2017profconsure.co.za/wp-content/uploads/2016/10/2017-Sizwe...AFFORDABLE CARE DENTAL BENEFIT TABLE 2017 FULL BENEFIT DENTAL BENEFIT TABLE 2017

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PRIMARY CARE DENTAL BENEFIT TABLE 2017

AFFORDABLE CARE DENTAL BENEFIT TABLE 2017

FULL BENEFIT DENTAL BENEFIT TABLE 2017

Dental benefits are paid at the Sizwe Dental tariff (SDT). Hospitalisation and certain specialised dentistry

procedures, 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 managed care protocols. 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 Specialised Dentistry. The Orthodontic

Benefit is NOT subject to the Specialised Dentistry Limit.

PRIMARY CARE

Conservative Dentistry Limit

of R2 800 per family

AFFORDABLE CARE

Conservative Dentistry

Limit of R3 200 per family

Specialised Dentistry


FULL BENEFIT





CO

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ER

VA

TIV

E D

EN

TIS

TR

Y

Consultations

2 annual check-ups per

beneficiary (once in 6

months).

Benefit is subject to

managed care protocols.

Covered at the SDT.



months).



Covered at the SDT.



months).



Covered at the SDT.

Sizwe Medical Fund Dental Benefit Table

2017

2

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





X-rays: Intra-oral Benefit is subject to


Covered at the SDT.



Covered at the SDT.



Covered at the SDT.

X-rays: Extra-oral

1 per beneficiary in a 3 year

period.



Covered at the SDT.

1 per beneficiary in a 3

year period.



Additional benefit may be

considered where

specialised dental

treatment is required.

Covered at the SDT.

1 per beneficiary in a 3

year period.



Additional benefit may be

considered where

specialised dental

treatment is required.

Covered at the SDT.

Oral Hygiene

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 fluoride is

limited to beneficiaries

from age 5 and younger

than 13 years of age.

Covered at the SDT.

Scheme exclusions:

Oral hygiene instruction

Oral hygiene evaluation

Professionally applied


treatments per beneficiary

(once in 6 months).



Benefit for fissure

sealants is limited to

beneficiaries younger than

16 years of age.





Covered at the SDT.

Scheme exclusions:



Professionally applied


treatments per


months).



Benefit for fissure

sealants is limited to

beneficiaries younger






Covered at the SDT.

Scheme exclusions:



3

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





fluoride for beneficiaries 13 years and older

Dental bleaching

fluoride for beneficiaries 13 years and older

Dental bleaching

Professionally applied fluoride for beneficiaries 13 years and older

Dental bleaching

Fillings

Benefit for fillings are

granted once per tooth in

365 days.

Benefit for re-treatment of a

tooth is subject to managed

care protocols.

Covered at the SDT.

A treatment plan and x-rays

may be required for multiple

fillings.

Scheme exclusions:

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



365 days.

Benefit for re-treatment of

a tooth is subject to


Covered at the SDT.

A treatment plan and x-

rays may be required for

multiple fillings.

Scheme exclusions:





Ozone therapy



365 days.

Benefit for re-treatment of

a tooth is subject to


Covered at the SDT.


rays may be required for

multiple fillings.

Scheme exclusions:





Ozone therapy

Root Canal

Therapy and

Extractions



Covered at the SDT.

Scheme exclusions:



Covered at the SDT.

Scheme exclusions:



Covered at the SDT.

Scheme exclusions:

4

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





Root canal therapy on primary (milk) teeth

Root canal therapy on wisdom teeth (3rd molars)

Direct and indirect pulp capping procedures







Plastic Dentures

and

associated

Laboratory costs

1 set of plastic dentures, full

or partial (an upper and a

lower) per beneficiary in a 4

year period.



Covered at the SDT.

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.


the laboratory fee of

mouthguards; the clinical

fee will be covered.

Scheme exclusions:

Diagnostic dentures and associated laboratory costs

Snoring appliances and associated laboratory costs

High impact acrylic

The cost of gold, precious metal, semiprecious metal and

1 set of plastic dentures

full or partial (an upper

and a lower) per

beneficiary in a 4 year

period.



Covered at the SDT.


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.


the laboratory fee of



Scheme exclusions:



High impact acrylic


1 set of plastic dentures,

full or partial (an upper

and a lower) per


period.



Covered at the SDT.

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



Scheme exclusions:



High impact acrylic


5

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





platinum foil

Laboratory delivery fees

Provisional dentures and associated laboratory costs

platinum foil



platinum foil



SP

EC

IAL

ISE

D D

EN

TIS

TR

Y

Partial Metal

Frame Dentures

and associated

Laboratory costs

No benefit

2 partial frames (an upper

and a lower) per


period, limited to 1 family

member per annum.



Covered at the SDT.

Scheme exclusions:

The metal base to full dentures and associated laboratory costs

High impact acrylic

The cost of gold, precious metal, semiprecious metal and platinum foil


2 partial frames (an

upper and a lower)

per beneficiary in a 5

year period, limited to 2

family members per

annum.



Covered at the SDT.

Scheme exclusions:


High impact acrylic



Crown & Bridge*

and

associated

Laboratory costs

A bridge

comprises 2 or

more crown units.

Each crown is

payable from the

No benefit

Pre-authorisation is

required.

1 crown per family per

year.



Covered at the SDT.


required.

3 crowns per family per

year.



Covered at the SDT.

6

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





available Crown

and Bridge

benefit.

Benefits for crowns are


a 5 year period.


rays may be requested.

Scheme exclusions:

Crown or crown retainers on wisdom teeth (3rd molars)

Pontics on 2nd molars

Crown and bridge procedures for cosmetic reasons and associated laboratory costs

Occlusal rehabilitations and associated laboratory costs

Provisional crowns and associated laboratory costs

Porcelain veneers and inlays and associated laboratory costs

Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs



Benefits for crowns are


a 5 year period.


rays may be requested.

Scheme exclusions:







Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs



Implants* and

associated

Laboratory costs

No benefit

No benefit


required.

2 implants per beneficiary

in a 5 year period.

7

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT







Covered at the SDT.

Cost of implant

component is limited to

R3 500 per implant.

Scheme exclusions:

Implants on wisdom teeth (3rd molars)

Dolder bars and associated abutments on implants including the associated laboratory costs


Orthodontics*

and associated

Laboratory costs

Note: NOT

subjected to the

Specialised

Dentistry Limit

No benefit


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 65% of

SDT.

Benefit for Orthodontic


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.

Benefit for Orthodontic

treatment will be granted

8

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





treatment will be granted

where function is

impaired.

Benefit will not be granted

where Orthodontic

treatment is required for

cosmetic reasons. The

associated Laboratory

costs will also not be

covered.

Only one family member

may commence

Orthodontic treatment in a

calendar year.

Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age.

Scheme exclusions:

Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory costs

Orthodontic re-treatment and any related laboratory costs

Invisible retainer material


where function is

impaired.

Benefit will not be

granted where

Orthodontic treatment is

required for cosmetic

reasons. The associated

Laboratory costs will also

not be covered.

Only one family member

may commence

Orthodontic treatment in

a calendar year.


Scheme exclusions:

Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory costs

Orthodontic re-treatment and any related laboratory costs



Periodontics*

Covered at the SDT.

Benefit is limited to

conservative, non-surgical

therapy only and will only

be applied to members who

are registered on the

Covered at the SDT.


conservative, non-surgical

therapy only and will only

be applied to members

who are registered on the

Covered at the SDT.


conservative, non-

surgical therapy only and

will only be applied to

members who are

9

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





Periodontal Programme.


required.



Surgical Periodontics – no

benefit.

Scheme exclusions:

Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth

Perio chip placement



required.



Surgical Periodontics – no

benefit.

Scheme exclusions:



registered on the



required.



Surgical Periodontics –

subject to managed care

protocols.

Scheme exclusions:



Maxillo-Facial

Surgery

and Oral

Pathology

Surgery in the dental chair:



Covered at the SDT.

Benefit for Temporo-

mandibular Joint (TMJ)

therapy is limited to non-

surgical intervention/

treatments.

The claims for oral

pathology procedures

(cysts and biopsies, the

surgical treatment of

tumours of the jaw and soft

tissue tumours) will only be

Surgery in the dental

chair:



Covered at the SDT.





treatments.

The claims for oral




tumours of the jaw and

soft tissue tumours) will

Surgery in the dental

chair:



Covered at the SDT.





treatments.

The claims for oral




tumours of the jaw and

soft tissue tumours) will

10

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





covered if supported by a

laboratory report that

confirms diagnosis.

Scheme exclusions:

Orthognathic (jaw correction) surgery

Bone augmentations

Bone and tissue regeneration procedures

The cost of bone regeneration material

The auto-transplantation of teeth

Sinus lift procedures

The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.

Surgery in hospital:

See Hospitalisation* below

only be covered if

supported by a laboratory

report that confirms

diagnosis.

Scheme exclusions:


Bone augmentations







See Hospitalisation*

below

only be covered if

supported by a laboratory

report that confirms

diagnosis.

Scheme exclusions:


Bone augmentations







See Hospitalisation*

below

11

HO

SP

ITA

LIS

AT

ION

AN

D A

NA

ES

TH

ET

ICS

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.

General anaesthetic


the removal of impacted

teeth. Benefit is subject to


The Hospital and

anaesthetist claims for the

following procedures 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:

Apicectomies

Dentectomies

Frenectomies

Implantology and associated surgical procedures


required.



applies.

Admission protocols

apply.

General anaesthetic


children under the age of

5 years for extensive

dental treatment.

General anaesthetic



teeth. Benefit is subject to


The Hospital and

anaesthetist claims for the

following procedures will

not be covered when


anaesthesia.

The payment of the dental

procedure will be



SDT:

Apicectomies

Dentectomies

Frenectomies



required.



applies.

Admission protocols

apply.

General anaesthetic


children under the age of

5 years for extensive

dental treatment.

General anaesthetic



teeth. Benefit is subject

to managed care

protocols.

The Hospital and

anaesthetist claims for

the following procedures

will not be covered when


anaesthesia.

The payment of the

dental procedure will be



SDT:

Apicectomies

Dentectomies

Frenectomies


Conservative dental Conservative dental Conservative dental

12

PRIMARY CARE



AFFORDABLE CARE





FULL BENEFIT





treatment (fillings, extractions and root canal therapy) for adults

Professional oral hygiene procedures

Surgical tooth exposure for orthodontic reasons

Scheme exclusions:

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 procedures performed under general anaesthesia




Scheme exclusions:








Scheme exclusions:





Laughing gas in

dental rooms



Covered at the SDT.



Covered at the SDT.



Covered at the SDT.

IV conscious

sedation in

rooms*


required.



Covered at the SDT.


extensive dental treatment.


required.



Covered at the SDT.


extensive dental

treatment.


required.



Covered at the SDT.


extensive dental

treatment.

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 procedures that are defined as unlisted

procedures

Primary specific exclusions:

Specialised dentistry: crowns & bridges, implants, orthodontics and surgical periodontics

Metal base to full dentures

Partial metal frame dentures

14

Sizwe Savings Care Dental Benefit Table 2017

Dental benefits are paid at the Sizwe dental tariff (SDT). Dental benefits are payable form available funds in the member's savings account for out of hospital services.

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.


SIZWE SAVINGS CARE OPTION

CO

NS

ER

VA

TIV

E D

EN

TIS

TR

Y

Consultations Available funds in the savings account.

Once in 6 months.

Benefit is subject to managed care protocols.

Covered at the SDT.

X-rays: Intra-oral Available funds in the savings account.


Covered at the SDT.

X-rays: Extra-oral Available funds in the savings account.

1 per beneficiary in a 3 year period.

Benefit is subject to managed care protocols. Additional benefit may be considered where specialised dental treatment is required.

Covered at the SDT.

Oral Hygiene Available funds in the savings account.

Once in 6 months.


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

15


years of age.

Covered at the SDT.

Scheme exclusions:



Professionally applied fluoride for beneficiaries 13 years and older

Dental bleaching

Fillings Available funds in the savings account.

Benefit for fillings are granted once per tooth in 365 days.

Benefit for re-treatment of a tooth is subject to managed care protocols.

Covered at the SDT.

A treatment plan and x-rays may be required for multiple fillings.

Scheme exclusions:





Ozone therapy

Root Canal Therapy and Extractions

Available funds in the savings account.


Covered at the SDT.

Scheme exclusions:




Plastic Dentures and associated Laboratory costs

Available funds in the savings account


Covered at the SDT.

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.

16


Scheme exclusions:



High impact acrylic

The cost of gold, precious metal, semi-precious metal and platinum foil



SP

EC

IAL

ISE

D D

EN

TIS

TR

Y Partial Metal

Frame Dentures and associated Laboratory costs



Covered at the SDT.

Scheme exclusions:


High impact acrylic



Crown & Bridge and associated Laboratory costs

A bridge comprises 2 or more crown units. Each crown is payable from the available Crown and Bridge benefit.

Available funds in the savings account


Covered at the SDT.

Benefits for crowns are granted once per tooth in a 5 year period.

A treatment plan and x-rays may be requested.

Scheme exclusions:







Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs.



Implants Available funds in the savings account.


Covered at the SDT.

Scheme exclusions:

Implants on wisdom teeth (3rd molars)

17


Dolder bars and associated abutments on implants including the associated laboratory costs


Orthodontics

and associated Laboratory costs




Scheme exclusions:

Orthognathic (jaw correction) and other orthodontic related surgery and any related Hospital cost including associated Laboratory costs

Orthodontic re-treatment and any related Laboratory costs



Periodontics Available funds in the savings account


Covered at the SDT.

Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme.

Scheme exclusions:



18


Maxillo-Facial Surgery

and Oral Pathology in Rooms

( excluding removal of impacted teeth under IV conscious sedation)

Available funds In the savings account


Covered at the SDT.

Benefit for Temporo-mandibular Joint (TMJ) therapy is limited to non-surgical intervention/treatments.

The claims for oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report that confirms diagnosis.

Scheme exclusions:


Bone augmentations







See Hospitalisation* below

19

SIZWE SAVINGS CARE OPTION H

OS

PIT

AL

ISA

TIO

N A

ND

AN

AE

ST

HE

TIC

S

Hospitalisation (general anaesthetic)*

Pre-authorisation is required.

A co-payment of R1 500 per hospital admission applies.


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.


The Hospital and anaesthetist claims for the following procedures 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:

Apicectomies

Dentectomies

Frenectomies


Conservative dental treatment (fillings, extractions and root canal therapy) for adults


Surgical tooth exposure for orthodontic reasons Scheme exclusions:



Where the only reason for the admission request is for a sterile facility.


Laughing gas in dental rooms



Covered at the SDT.

IV conscious sedation in rooms*


Removal of impacted teeth only.


Covered at the SDT.

20






Pulp tests




Special report






Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures

21

Sizwe Hospital 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.


SIZWE HOSPITAL CARE OPTION

CO

NS

ER

VA

TIV

E D

EN

TIS

TR

Y

Consultations No Benefit

X-rays: Intra-oral No Benefit

X-rays: Extra-oral No Benefit

Oral Hygiene No Benefit

Fillings No Benefit

Root Canal Therapy and Extractions

No Benefit

Plastic Dentures and associated Laboratory costs

No Benefit

22

SIZWE HOSPITAL CARE OPTION S

PE

CIA

LIS

ED

DE

NT

IST

RY

Partial Metal Frame Dentures and associated Laboratory costs

No Benefit

Crown & Bridge and associated Laboratory costs

No Benefit

Implants No Benefit

Orthodontics

and associated Laboratory costs

No Benefit

Periodontics No Benefit

Maxillo-Facial Surgery

and Oral Pathology in Rooms

( excluding removal of impacted teeth under IV conscious sedation)

No Benefit

23

SIZWE HOSPITAL CARE OPTION H

OS

PIT

AL

ISA

TIO

N A

ND

AN

AE

ST

HE

TIC

S

Hospitalisation (general anaesthetic)*


A co-payment of R1 500 per hospital admission applies.


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.


Scheme exclusions:



Where the only reason for the admission request is for a sterile facility.


Laughing gas in dental rooms

No Benefit

IV conscious sedation in rooms*


Limited to the In-Hospital dental benefits.


Covered at the SDT.






Pulp tests




Special report






Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures

Documents

Sizwe Medical Fund Dental Benefit Table 2017profconsure.co.za/wp-content/uploads/2016/10/2017-Sizwe...AFFORDABLE CARE DENTAL BENEFIT TABLE 2017 FULL BENEFIT DENTAL BENEFIT TABLE 2017