Covered Dental Care Services Sample Clauses

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. • Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. • X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. • Cleanings (Prophylaxis) - two (2) cleanings per plan year. • Fluoride Treatments - two (2) fluoride treatments per plan year. • Sealants - permanent molars only; one sealant per tooth in a 36-month period. • Space Maintainers. • Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. • Fillings. • Simple Extractions - the removal of an erupted tooth (non-surgical). • Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. • Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. • Therapeutic Pulpotomies. • Root Canal Therapy. • Non-Surgical Periodontal Services. • Surgical Periodontal Services - predetermination is recommended. • Periodontal Maintenance - two (2) services in a plan year. • Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. • Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. • Oral Surgery Services. • Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. • Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. • General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. • Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if:...
Sample 1Sample 2Sample 3See All (94)
AutoNDA by SimpleDocs
Covered Dental Care Services. We cover the following services when rendered by a dentist. All covered dental services are subject to the provisions below. See the Summary of Benefits to determine level of coverage and the amount you pay. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See The Summary of Benefits to determine if a service or category of service is covered. This agreement covers multi-stage procedures which have a start date before the effective date of this agreement if:  the multi-stage procedures have a completion date after the effective date of this agreement; and  the multi-stage procedures are covered dental services under this agreement. Subject to any plan year or other maximums, we will pay up to our allowance less any benefits paid or payable under any previous plan for multi-stage procedures. Pediatric Dental Care Services In accordance with PPACA, this agreement provides coverage for the dentally necessary services listed in the Summary of Benefits for an enrolled child under the age of nineteen (19), when rendered by a network dentist or non-network dentist. The coverage for dental care services rendered to an enrolled child will end for the child on the first day of the month following their 19th birthday, unless otherwise specified in the Summary of Benefits. If a covered dental care service is rendered more than our contractually specified treatment time or age limitations, which are based on our dental policies and related guidelines, it is not covered.
Sample 1Sample 2

Related to Covered Dental Care Services

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s

  • Dental Services The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. Dialysis Services • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Time is Money Join Law Insider Premium to draft better contracts faster.