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Tri-State Plan SPD >> Dental Benefits
This booklet is a description of dental benefits for the Building Service 32BJ Health Fund’s Tri-State Plan. This replaces the information presented in the Summary Plan Description (SPD), pages 45–53, and is effective December 1, 2007.
Tri-State Plan SPD
>> Dental Benefits
How the Plan Works
The Plan provides coverage for necessary dental care received through:
Necessary dental care is a service or supply that is required to identify or treat a dental condition, disease or injury. The fact that a dentist prescribes or approves a service or supply or a court orders a service or supply to be rendered does not make it dentally necessary. The service or supply must be all of the following:
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provided by a dentist, or solely in the case of cleaning or scaling of teeth, performed by a licensed, registered dental hygienist under the supervision and direction of a dentist
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consistent with the symptoms, diagnosis or treatment of the condition, disease or injury
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consistent with standards of good dental practice
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not solely for the patient’s or the dentist’s convenience, and
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the most appropriate supply or level of service that can safely be provided to the patient.
Covered services are listed in the “Schedule of Covered Dental Services” (see the "Schedule of Covered Dental Services"), subject to frequency limitations that are stated in that Schedule. The Plan pays no benefits for procedures that are not on the Schedule, but may provide an alternate benefit if approved by Delta Dental of New York, Inc. (Delta Dental) on behalf of the Fund. Whether you have to pay for those services and, if so, how much, depends on whether you choose to receive your dental care from a Delta Dental participating PPO dental provider or from a non-participating dentist.
Annual Maximum
The Dental Plan provides coverage of up to $1,000 per covered individual per calendar year. There is a separate lifetime maximum of up to $1000 for orthodontic services for dependent children.
Participating Dental Providers
The Plan’s dental benefits include a “participating dental provider” feature through Delta Dental. The Delta Dental PPO is the Plan’s participating dental provider network. Dentists who participate in the Delta Dental PPO have agreed to accept the amount that Delta Dental pays as either payment in full for diagnostic and preventive services or partial payment for other dental services. If you choose to receive your care from a participating dental provider:
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you will not have to pay anything for covered dental care that is diagnostic or preventive
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for all other services, you will pay the difference between the fee schedule Delta Dental pays and the applicable maximum plan allowance under the Delta Dental PPO.
Non-Participating Dentists
The Plan will pay for dental work performed by any properly accredited dentist, but the Plan will pay no more than what Delta Dental would have paid a participating Delta Dental PPO dentist. Contact Delta Dental’s Customer Service at 1-800-932-0783 to find out what their reimbursement is for each dental procedure/service you require.
You will be required to pay the dentist’s full charges. You will file a claim with Delta Dental (see "Filing Dental Claims") and will be reimbursed according to the Delta Dental fee schedule for each procedure.
The Fund will pay the smaller of the dentist’s actual charge for a covered dental service or the allowed amount for that procedure according to Delta Dental’s PPO fee schedule.
Predeterminations/Pre-treatment Estimates
Determine costs ahead of time by asking your Delta Dental participating dentist to submit the treatment plan to Delta Dental for a predetermination of benefits before any treatment is provided. Delta Dental will verify your specific plan coverage and the cost of the treatment and provide an estimate of your coinsurance and what Delta Dental will pay. Predeterminations are free and help you and your dentist make informed decisions about the cost of your treatment.
What Dental Services Are Covered
The Plan covers a wide range of dental services, including:
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Preventive and diagnostic services such as routine oral exams, cleanings, X-rays, topical fluoride applications, space maintainers and sealants
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Basic therapeutic services such as extractions and oral surgery, intravenous conscious sedation when medically necessary for oral surgery, gum treatment, gum surgery, fillings and root canal therapy
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Major services such as fixed bridgework, crowns, and dentures
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Orthodontic services such as diagnostic procedures and appliances to realign teeth. There is a separate lifetime maximum on orthodontic services of $1,000 per patient.
See the "Schedule of Covered Dental Services" section for details.
Frequency Limitations
Benefits are subject to the frequency limits shown on the "Schedule of Covered Dental Services" section.
Schedule of Covered Dental Services
Alternate Benefit
There is often more than one way to treat a given dental problem. For example, a tooth could be repaired with an amalgam filling, a resin composite or a crown. If this is the case, the Plan will generally limit benefits to the least expensive method of treatment that is appropriate and that meets acceptable dental standards. For example, if your tooth can be filled with amalgam and you or your dentist decide to use a crown instead, the Plan pays benefits based on the amalgam. You will have to pay the difference.
What Is Not Covered
The Plan's dental coverage will not reimburse or make payments for the following:
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any services performed before a patient becomes eligible for benefits or
after a patient’s eligibility terminates, even if a treatment plan has been
approved
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reimbursement for any services in excess of the frequency limitations
specified in the Schedule of Covered Dental Services
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charges in excess of the Delta Dental Allowed Amounts – contact Delta
Dental Member Services for allowed amounts for each covered service
– or the annual or lifetime maximum.
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treatment for accidental injury to natural teeth that is provided more
than 12 months after the date of the accident
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services or supplies that the Plan determines are experimental or
investigative in nature
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services or treatments that the Plan determines do not have a
reasonably favorable prognosis
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any treatment performed principally for cosmetic reasons, including,
but not limited to, laminate, veneers and tooth bleaching
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special techniques, including precision dentures, overdenture,
characterization or personalization of crowns, dentures, fillings or any
other service. This includes, but is not limited to, precision attachments
and stress-breakers. Full or partial dentures that require special
techniques and time due to special problems, such as loss of supporting
bone structure, are also excluded.
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any procedures, appliances or restorations that alter the “bite,” or the
way the teeth meet (also referred to as occlusion and vertical dimension)
and/or restore or maintain the bite, except as provided under
orthodontic benefits. Such procedures include, but are not limited
to, equilibration, periodontal splinting, full-mouth rehabilitation,
restoration of tooth structure lost from attrition, and restoration for
misalignment of teeth.
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any procedures involving full-mouth reconstruction, or any services
related to dental implants, including any surgical implant with a
prosthetic device attached to it
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diagnosis and/or treatment of jaw joint problems, including
temporomandibular joint disorder (TMJ) syndrome, craniomandibular
disorders, or other conditions of the joint linking the jaw bone and skull
or the complex of muscles, nerves, and other tissue related to that joint
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double or multiple abutments
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treatment for self-inflicted injury or illness
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treatment to correct harmful habits, including, but not limited to,
smoking and myofunctional therapy
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habit-breaking appliances, except under the orthodontics benefit
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services for plaque-control programs, oral hygiene instruction, and
dietary counseling
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services related to the replacement or repair of appliances or devices,
including:
- duplicate dentures, appliances or devices
- the replacement of lost, missing or stolen dentures and appliances
less than five years from the date of insertion or the payment date
- replacement of existing dentures, bridges or appliances that can be
made useable according to dental standards
- adjustments to a prosthetic device within the first six months of its
placement that were not included in the device’s original price, and
- replacement or repair of orthodontic appliances.
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drugs or medications used or dispensed in the dentist’s office
(any prescriptions that are required may be covered by the Plan’s
prescription drug benefits – see the "Prescription Drug Benefits" section)
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charges for novocaine, xylocaine or any similar local anesthetic when
the charge is made separately from a covered dental expense
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additional fees charged by a dentist for hospital treatment
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services for which a participant has contractual rights to recover cost,
whether a claim is asserted or not, under Workers’ Compensation, or
automobile, medical, personal injury protection, homeowners or other
no-fault insurance
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treatment of conditions caused by war or any act of war, whether
declared or undeclared, or a condition contracted or accident occurring
while on full-time active duty in the armed forces of any country or
combination of countries
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any portion of the charges for which benefits are payable under any
other part of the Plan
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if a participant transfers from the care of one dentist to another dentist
during the course of treatment, or if more than one dentist renders
services for the same procedure, the Plan will not pay benefits greater
than what it would have paid if the service had been rendered by one
dentist
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transportation to or from treatment
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expenses incurred for broken appointments
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fees for completing reports or for providing records, or
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any procedures not listed under the Schedule of Covered Dental Services.
Claims and Appeals Procedures
Filing Dental Claims
When you see a participating Delta Dental provider, this provider will file all claims for you directly with Delta Dental, the administrator for the Plan’s dental coverage. Delta Dental will pay the participating Delta Dental providers directly.
You have to file a claim when you receive care from dentists or other providers or facilities not in the Plan’s participating dental provider network. You can obtain a claim form by visiting Delta Dental’s web site at www.deltadentalins.com. Here is what you need to know when you file a dental claim when you do not use a participating dental provider.
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Only an original, fully completed ADA claim form or approved treatment plan will be accepted for review.
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All necessary diagnostic information must accompany the claim.
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When you are the patient, your original signature or signature on file is acceptable on all claims for payment. If the patient is a child, an original signature or signature on file of the child’s parent or guardian is acceptable.
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All claims must be received by Delta Dental within 180 days after services were rendered.
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Payment for all services received from a non-participating dental provider will be made to you. It is your responsibility to pay the dentist directly for services you receive from a non-participating dentist. The Plan will not assign benefits to a non-participating dental provider.
The Plan reserves the right to withhold payment or request reimbursement from providers or participants for services that do not meet acceptable standards, as determined by its consultants or professional staff.
Where to Send Claim Forms
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| Benefit |
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Filing Address |
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| Dental (non-participating providers only; no claim forms are necessary for participating providers) |
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Delta Dental
One Delta Drive
Mechanicsburg, PA 17055
Attn: Claims Department |
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Where to File An Appeal
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| Benefit |
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Write to: |
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Or Call: |
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| Dental |
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Delta Dental
One Delta Drive
Mechanicsburg, PA 17055
Attn: Dental Affairs
Committee |
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Appeals are only accepted in writing |
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