Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist would exceed $300.00, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in a payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist.
Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist would exceed $300, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental care which is cosmetic; - Completion of claim forms; - Broken appointments; - Dental care covered under a medical plan provided by an employer or government; - Which, in the absence of coverage, there would be no charge; - Stainless steel crowns on permanent teeth; - Oral hygiene instruction or nutritional counselling; - Protective athletic appliances; - Prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not covered, or which were ordered while the person was covered but which were finally installed or delivered after this benefit is discontinued; - A full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement of lost or stolen appliances.
Predetermination of Benefits. If a course of treatment can reasonably be expected to involve Covered Dental Expenses of $200.00 or more, a description of the procedures to be performed and an estimate of the dentist's charges must be filed with the prepayment agency prior to the commencement of the course of treatment. The prepayment agency will notify the employee and the dentist of the benefits certified as payable based upon such course of treatment. In determining the amount of benefits payable, consideration will be given to alternate procedures, services, or courses of treatment that may be performed for the dental condition concerned in order to accomplish the desired result. The amount included as certified dental expenses will be the appropriate amount as provided in Sections III and IV, determined in accordance with the limitations set forth in Section VI. If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, the prepayment agency reserves the right to make a determination of benefits payable taking into account alternate procedures, services or courses of treatment, based on accepted standards of dental practice. To the extent verification of Covered Dental Expenses cannot reasonably be made by the prepayment agency, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. This predetermination requirement will not apply to courses of treatment under $200.00 or to emergency treatment, routine oral examinations, x rays, prophylaxis and fluoride treatments.
Predetermination of Benefits. If other than brief and routine dental services are needed, an Attending Dentist’s Statement (claim form) listing the proposed services should be submitted to Delta Dental Plan of Ohio in advance of your dentist completing such services. The Predetermination of Benefits procedure will enable Delta Plan of Ohio to verify eligibility and state the amount of benefit payable by your program.
Predetermination of Benefits. If a course of treatment is expected to involve charges for dental services in certain categories of care such as Periodontics, Endodontics, Special Services, Prosthetic Services or Orthodontics of $300 or more, it is recommended that a description of the procedures to be performed, an estimate of the dentist's charges and an appropriate x-ray pertaining to the treatment, be filed by the dentist with us in writing, prior to the course of treatment.
Predetermination of Benefits. If dental expenses in connection with a course of treatment planned by a dentist for a covered family member will exceed $200, the proposed course of treatment should be filed with and approved by the Insurance Company prior to the commencement of treatment. Failure to file and obtain approval may result in benefits for the course of treatment in a lesser amount than would otherwise have been payable, because of the difficulty of determining the necessity for the types of services involved after they have been rendered. After reviewing the proposed course of treatment, the Insurance Company will notify both you and your dentist of the estimated payment.
Predetermination of Benefits. Predetermination of Benefits should be requested if the cost of the recommended treatment Plan exceeds Two Hundred Fifty Dollars ($250). DDPOK will issue an estimate of benefits regarding the Attending Dentist Statement (claim form) when satisfied that the patient is eligible for Benefits. The Predetermination will be for a maximum period of three hundred sixty−five (365) days from the date of Predetermination by DDPOK (one hundred eighty [180] for Periodontal procedures), but not longer than the period this Plan is in effect.
Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist would exceed proposed details and x-rays should be submitted to the Plan Administrator for approval, Failure to do so may result in a payment of a lesser benefit amount because of the in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist.
Predetermination of Benefits. Treatment plans that involve Covered Services which include prosthodontic services, orthodontic services, individual crowns (except stainless steel), gold restorations, surgical periodontics, endodontics, and oral surgery except for simple extraction of a single tooth, should be submitted to DDKS for predetermination of benefits. Failure to do so may result in a loss of benefits if, in the professional judgment of DDKS, such treatment is not necessary or a lesser procedure could have restored the tooth or dental arch to a reasonable degree of functionality. A predetermination of benefits does not obligate DDKS to provide any benefits associated therewith if the Enrollee is no longer eligible to receive such benefits at the time the Covered Services are per formed. A predetermination of benefits is only effective with respect to Covered Services which commence within ninety (90) days of the date the treatment plan is submitted to DDKS by the treating Dentist. Otherwise a new predetermination of benefits must be sought.
Predetermination of Benefits. If a Course of Treatment for non-emergency services can reasonably be expected to involve Eligible Dental Expenses in excess of $300, a description of the procedures to be performed and an estimate of the Dentist’s charge should be filed with and predetermined by BCBSTX prior to the commencement of treatment. BCBSTX may request copies of existing x-rays, photographs, models, and any other records used by the Dentist in developing the Course of Treatment. BCBSTX will review the reports and materials, taking into consideration alternative Courses of Treatment. BCBSTX will notify you and the Dentist of the benefits to be provided under the Plan. Predetermination gives you and your Dentist the opportunity to know the extent of the benefits available. Benefit payments may be reduced based on any claims paid after a predetermination estimate is provided. Eligible Dental Expenses The Plan provides coverage for services and supplies that are considered Dentally Necessary. The benefit percentage to be applied to each category of service is shown on the DENTAL SCHEDULE OF COVERAGE. For benefits available for Eligible Dental Expenses, please refer to the DENTAL SCHEDULE OF COVERAGE in this Rider. Your benefits are calculated on a Calendar Year benefit period basis unless otherwise stated. At the end of a Calendar Year, a new benefit period starts for each Participant.
