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Section 7 General Exclusions – Things We Do Not Cover
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Section 7 General Exclusions – Things We Do Not Cover The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition. We do not cover the following: Plan Exclusions • Services which are covered under Medicare, worker’s compensation or employer’s liability laws. • Services which are not necessary for the patient’s dental health as determined by the Plan. • Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan. • Oral surgery requiring the setting of fractures or dislocations. • Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the opinion of the Plan, such services should not be performed in a dental office. • Dispensing of drugs. • Hospitalization for any dental procedure. • Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared. • Replacement due to loss or theft of prosthetic appliance. • Procedures not listed as covered benefits under this Plan. • Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan (with the exception of out-of-area emergency dental services). • Services related to the treatment of TMD (Temporomandibular Disorder). • Services performed by a Participating Specialist without a referral from a Participating General Dentist (with the exception of orthodontics). • Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. • Plaque control programs, oral hygiene instruction, and dietary instructions. • Nitrous oxide and oral sedation. Plan Limitations • Two (2) evaluations are covered per calendar year including a maximum of one (1) comprehensive evaluation. All oral evaluations will be considered integral when provided on the same date of service by the same dentist. • One (1) problem focused exam is covered per calendar year, per patient. • Two (2) teeth cleanings (prophylaxis) are covered per calendar year, per patient (one (1) additional cleaning is covered during pregnancy and for diabetic patients). Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such. • Two (2) topical fluorides or fluoride varnishes are covered per calendar year, per patient. • Two (2) bitewing x-rays are covered per calendar year, per patient. • One (1) set of full mouth x-rays or panoramic film is covered every three (3) years, per patient. • One (1) sealant per tooth is covered per 36 months, up to age 18 (limited to permanent 1st and 2nd molars). Sealants with a restoration on same date of service are considered integral. • Distal shoe space maintainer limited to once per lifetime. 27 2018
Enroll at www.BENEFEDS.com • Replacement of a filling is covered if it is more than two (2) years from the date of original placement. • Replacement of a bridge, crown or denture is covered if it is more than five (5) years from the date of original placement. • Crown, implant and bridge fees apply to treatment involving five (5) or fewer units when presented in a single treatment plan. Additional crown, implant or bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%. • One (1) relining and rebasing of dentures is covered every 36 months, per patient. • Retreatment of root canal is covered if it is more than two (2) years from the original treatment. • Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy. • One (1) root planing or scaling is covered every 24 months per quadrant, per patient. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing, or periodontal surgical procedures, in the same area of the mouth is not covered. • Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation and in lieu of a covered D1110/D1120, limited to once per two years. • One (1) full mouth debridement is covered per lifetime, per patient. • Procedure Code D4381 is limited to one (1) benefit per tooth for three (3) teeth per quadrant or a total of 12 teeth for all four (4) quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater. • One (1) periodontal surgery of any type, including any associated material, is covered every 36 months per quadrant or surgical site. • Periodontal maintenance after active therapy is covered two (2) times per calendar year, within 24 months after definitive periodontal therapy. • Stainless steel crowns (D2930, D2931) are covered through age 14, or when placed as a result of accidental injury and one per tooth, per lifetime. • Onlays, crowns, and posts and cores for members 12 years of age or younger are excluded from coverage, unless pre- approved by the Plan. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. Posts are eligible only when provided as part of a crown buildup or implant and are considered integral to the buildup or implant. • Fixed partial dentures, buildups and posts and cores for members under 16 years of age are not covered unless approved by the Plan. • Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival flap procedure are not covered. • Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth. • Surgical revision procedure (D4268) is considered integral to all other periodontal procedures. • One (1) scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure, per two (2) years. • Coronectomy, intentional partial tooth removal, one (1) per lifetime. • Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless approved by the Plan. • Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions • Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD). Occlusal guards are limited to one (1) per 12 consecutive month period. • Athletic mouth guards are limited to one (1) per 12 consecutive month period. 28 2018
Enroll at www.BENEFEDS.com • Teledentistry, synchronous (D9995) or asynchronous (D9996), limited to two (2) per calendar year (when available). The Invisalign system is a discounted benefit that applies to D8070, D8080 and D8090. Additional costs incurred will become the patient’s responsibility. 29 2018
Enroll at www.BENEFEDS.com Section 8 Claims Filing and Disputed Claims Processes For in-network services, there are no claims for you to file. This plan does not offer an out-of-network benefit. If you see an out-of-network provider for emergency services, the claim (a standard ADA claim form) should be submitted to: Dominion Dental Services, Inc. P.O. Box 1126 Elk Grove Village, IL 60009 If you see an international dentist for emergency services, the provider or member should submit a claim form with the following information: name of the country in which the work was performed, the dentist’s name, the American Dental Association code(s), the tooth number(s) and the date(s) of service. Claims must be submitted in U.S. dollars and mailed to the address shown above. How to File a Claim for Covered Services For emergency and international claims, you have one year from the date of service to file your claim.
Follow this disputed claims process, if you disagree with our decision on your claim or request for services. The FEDVIP law does not provide for OPM to review disputed
1 Ask us in writing to reconsider our initial decision. You must submit a formal written statement to our Member Services Department c/o Dominion Dental Services, Inc. at: 251 18th Street South, Suite 900 Arlington, VA 22202 within one (1) year from occurrence of the events upon which the grievance is based, and must contain a statement of the action requested, your name, address, telephone number, Member number, signature and the date.
pay or deny the claim and communicate such decision back to you. However, if the grievance involves collection of information from outside our service area, an additional thirty (30) days will be allowed for processing. 3 If the dispute is not resolved through the reconsideration process, you may request a review of the denial. You must request reconsideration by the Grievance Panel within sixty (60) days after receipt of the initial grievance written decision by submitting a written request to the our Member Services Department c/o Dominion Dental Services, Inc. 251 18th Street South, Suite 900 Arlington, VA 22202.
mutually agreed upon by us and OPM, review the decision. The decision of the independent third party is binding and is the final review of your claim. To request a third-party review, you must submit a written request to our Member Services Department c/o Dominion Dental Services, Inc. at: 251 18th Street South, Suite 900 Arlington, VA 22202.
Disputed Claims Process 30
2018 Enroll at www.BENEFEDS.com Section 9 Definitions of Terms We Use in This Brochure The maximum annual benefit that you can receive per person. This plan does not have an annual benefit maximum.
Federal retirees (who retired on an immediate annuity), and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity. This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers. Annuitants are sometimes called retirees. Annuitants The enrollment and premium administration system for FEDVIP. BENEFEDS Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure.
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants and x-rays.
Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
Major services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges and prosthodontic services such as complete dentures. Class C Services Orthodontic services. Class D Services Copay or copayment is a fixed amount of money you pay directly to the dentist when you receive covered services.
Treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by an assigned plan provider. Emergency Services The Federal employee or annuitant enrolled in this plan. Enrollee Federal Employees Dental and Vision Insurance Program. FEDVIP The standards set by the American Dental Association or which are customarily used for dental care. Dominion Dental reserves the right to determine the level of necessary treatment. Generally Accepted Dental Protocols The exclusion of any service or supply rendered to replace a tooth lost prior to the effective date of coverage. When the procedure/appliance is to replace only the tooth lost prior to the member’s effective date, the procedure/appliance is not covered. When the missing tooth is repaired in conjunction with other extractions after the effective date, the procedure/appliance is covered. Missing Tooth Clause The amount we use to determine our payment for out-of-network services. Plan Allowance Any disease or condition of the teeth or supporting structures which existed on the effective date of coverage.
Dominion Dental Services, Inc. We/Us Enrollee or eligible family member. You 31
2018 Enroll at www.BENEFEDS.com Stop Health Care Fraud! Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance Program premium.
• Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your providers, plan, BENEFEDS, or OPM. • Let only the appropriate providers review your clinical record or recommend services. • Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. • Carefully review your explanation of benefits (EOBs) statements. • Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or service. • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following: - Call the provider and ask for an explanation. There may be an error. - If the provider does not resolve the matter, call us at 855-836-6337 and explain the situation. • Do not maintain as a family member on your policy: - Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or - Your child over age 22 (unless he/she is disabled and incapable of self- support). If you have any questions about the eligibility of a dependent, please contact BENEFEDS. Be sure to review Section 1, Eligibility, of this brochure prior to submitting your enrollment or obtaining benefits. Fraud or intentional misrepresentation of material fact is prohibited under the plan. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when you are no longer eligible. 32
2018 Enroll at www.BENEFEDS.com Summary of Benefits •
of this brochure, for more detail. • If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680. Benefit You Pay: High Option Benefits Class A (Basic) Services – preventive and diagnostic Copay Class B (Intermediate) Services – includes minor restorative services Copay
Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services Copay Class D Services – orthodontic No Lifetime Maximum Copay
33 2018
Enroll at www.BENEFEDS.com Rate Information
How to find your monthly and bi-weekly rates:
• In the first chart below, look up your state or zip code to determine your Rating Area. • In the second chart below, match your Rating Area to your enrollment type and plan option.
Premium Rating Areas by State/Zip Code (first three digits) State 3 Digit Zip Code Rating Area State 3 Digit Zip Code Rating Area DC Entire State 4 PA 173-174
4 DE Entire State 5 PA 189-196
5 MD 206-212, 214, 217 4 PA Rest of State 1 MD 219
5 VA 231-232, 238 3 MD Rest of State 2 VA 201, 220-227, 233-237 4 NJ 080-084
5
Monthly Rates
Rating Area High Option Self Only High Option Self Plus One High Option Self and Family Standard Option Self Only Standard Option Self Plus One Standard Option Self and Family 1 $22.17 $44.33 $66.50
$13.02 $26.04
$39.07 2 $22.97 $45.96 $68.92
$13.59 $27.17
$40.76 3 $24.14 $48.30 $72.43
$15.15 $30.31
$45.46 4 $28.08 $56.18 $84.26
$18.07 $36.14
$54.21 5 $32.98 $65.98 $98.95
$19.26 $38.55
$57.81
Bi-Weekly Rates
Rating Area High Option Self Only High Option Self Plus One High Option Self and Family Standard Option Self Only Standard Option Self Plus One Standard Option Self and Family 1 $10.23 $20.46 $30.69
$6.01 $12.02
$18.03 2 $10.60 $21.21 $31.81
$6.27 $12.54
$18.81 3 $11.14 $22.29 $33.43
$6.99 $13.99
$20.98 4 $12.96 $25.93 $38.89
$8.34 $16.68
$25.02 5 $15.22 $30.45 $45.67
$8.89 $17.79
$26.68
2018
34 Enroll at www.BENEFEDS.com Document Outline
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