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Dental Benefits
How
to Access Dental Services | Dental
Services—What is Covered
Dental Care Benefit
Limitations | Dental
Exclusions—What is Not Covered
How to Access Dental Services
Dental Benefits are Provider through United Concordia. To receive dental services for your enrolled child, take your child to a participating United Concordia dentist.
Present your child’s Dental ID Card to the dentist participating in the Advantage Network in order to receive covered dental benefits. The dentist will handle all the paperwork for you.
Payment will be sent directly to the participating dentist. You will not be responsible for any portion of the bill for covered services.
Dental Services—What is Covered
1. Diagnostic Services
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A. |
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One routine oral examination every six months |
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B. |
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Dental x-rays
- Full mouth x-rays, not more than once every five years
- Bitewing x-rays, not more than twice every 12 months
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2. Preventive Services
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A. |
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Routine cleaning, scaling and polishing of teeth, not more than once every six months |
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B. |
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Topical fluoride application, not more than once every six months |
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C. |
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Space maintainers that replace premature loss of primary posterior molars or permanent first molars |
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D. |
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Sealants for children five years of age through nine years of age on permanent first molars and from 10 years of age through 14 years of age on permanent second molars, only if teeth to be sealed are free of proximal cavities and there are no previous restorations on the surface to be sealed. There is a limitation of one sealant per tooth with no repeats. |
3. Minor Restorations
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A. |
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Amalgam (silver) and resin based composite (white) for all permanent and deciduous teeth). Amalgam restorations for all deciduous teeth. Other restorations not covered unless there is a special need. |
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B. |
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Core build-ups including any pins, prefabricated post and core, cast post and core in addition to a crown. There is a five-year limitation for replacement. One build-up or cast post and core is allowed within a five-year period. |
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C. |
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Resin, porcelain and full cast single crowns for permanent teeth; limited to once in a five year period. Stainless steel crowns for deciduous teeth only; limited to once per tooth per lifetime. |
4. General Services
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Palliative (pain relief) emergency treatment of an acute condition requiring immediate care |
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B. |
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Simple extractions, as dentally necessary |
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C. |
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Surgical extractions |
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D. |
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Pulpotomies for deciduous teeth only |
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E. |
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Endodontic (Root Canal) therapy for permanent teeth, limited to once per tooth, per lifetime |
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F. |
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Administration of anesthesia in connection with the performance of covered services when provided by or under the direct supervision of a dentist other than the surgeon, assistant surgeon or attending dentist |
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G. |
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Consultations, limited to one consultation per consultant during any one period of hospitalization when your child is an inpatient and the dental condition requires such consultation |
Dental Care Benefit Limitations
- If an eligible child transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist performs covered services for one dental procedure, the plan shall be liable for not more than the amount that it would have been liable for had but one dentist performed the covered service.
- In all cases involving covered services in which the dentist and an eligible child or the eligible child’s family select a more expensive course of treatment than is customarily provided by the dental profession, consistent with sound professional standards of dental practice for the dental condition concerned, payment under this benefit will be based on the charge allowance for the lesser procedure.
- A contract between the eligible child or the eligible child’s family and dentist prior to the effective date of coverage under the contract is not invalidated by a subsequent contract made between the plan and/or the eligible child or the eligible child’s family and/or dentist. The eligible child or the eligible child’s family will be liable for any difference due to the dentist under such a contract after the the plan liability has been satisfied.
- Any additional treatment that is necessitated by lack of cooperation by the eligible child or the eligible child’s family with the dentist or noncompliance with prescribed dental care that results in additional liability will be the responsibility of the eligible child or the eligible child’s family.
Dental Exclusions—What is Not Covered
The following are not covered under the dental benefits of CHIP:
- Labial veneers and laminates done for cosmetic purposes. However, when performed for restorative purposes, labial veneers and laminates are covered under the same conditions and to the same extent that amalgam and composite restorations are covered.
- Duplicate and temporary devices, appliances and services
- Plaque control programs and oral hygiene and dietary instructions
- Implantology and related services
- Alteration of vertical dimension and the restoration or maintenance of occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, restoration of tooth structure lost from attrition, and restoration for mal-alignment of the teeth.
- Local anesthesia when billed for separately by a dentist
- Gold foil restorations
- Services submitted by another professional provider and/or a dentist which are the same services performed on the same dates for the same patient
- Oral surgery
- Prosthetics
- Periodontics
- Orthodontics
- Services covered under the medical portion of the contract.
- Any services or items not specifically listed under the covered services.
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