Limitations & Exclusions

The following exclusions are common to most dental benefit plans:

 

1. Any dental services which were not rendered or approved by a participating dentist except in cases of out-of-area dental emergency

This only applies to patients who are enrolled in managed care plans that operate through a limited number of participating dentists. Such plans require that services be rendered only by providers under contract with the insurer.

2. A service not furnished by a Dentist, unless the service is performed by a licensed dental hygienist under the supervision of a dentist or for an x-ray ordered by a dentist.

Under the dental contract, benefits can only be provided for services rendered by licensed practitioners.

3. Treatment of a disease, defect, or injury covered by a major medical plan, Workmen's Compensation Law, occupational disease law, or similar legislation.

This excludes services that may be covered by other plans or federal/state benefit programs. In such cases, private dental coverage is not available.

4. General anesthesia, analgesia and any service rendered in a hospital environment.

If these services are included in a particular plan, they would only be covered in conjunction with covered oral surgery rendered in a dental office. There would be no benefit for hospital charges related to these services.

5. Any dental procedures which are undertaken primarily for cosmetic reasons, or dental care to treat accidental injuries, congenital or developmental malformations.

Dental benefit plans are only intended to provide coverage for the treatment of dental disease and other tooth related problems. Services rendered for cosmetic purposes are not covered.

6. Restorations, crowns or fixed prosthetics when acceptable results can be achieved with alternative methods or materials. In cases where the selection of a more expensive treatment plan is decided upon, the Plan will allow for the least costly alternative and the patient is responsible for all additional fees charged by the dentist.

Because dental conditions can often be treated in many ways, coverage must be limited to the least costly method that would produce a satisfactory result

7. Services which were started prior to the person becoming covered under this plan.

Benefits only apply to treatment rendered while a person is covered under the plan. Services provided before (or after) a period of eligibility can not be covered.

8. Implants, precision attachments or other personalized restorations or specialized techniques.

Most plans have such services excluded because they may have limited success and because they may be subject to alternate treatment plans.

9. Broken Appointments - If specified by Plan Dentist for appointments not canceled 24 hours in advance, there is a $30.00 charge.

This only applies to patients enrolled in Managed Care Plans that operate through participating dentists. By calling to cancel a scheduled visit, the dentist may be able to appoint another patient in need of care. If the time is forfeited without proper notice, the dentist may charge for the lost time.

10. Replacement of any existing crown, bridge or denture, which can be made serviceable according to common dental standards.

This clarifies that the plan will provide benefits only for services that medically necessary. New dental prosthetics are only provided if existing appliances are not functional and cannot be repaired.

11. Procedures, appliances or restorations whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth, or restore occlusion.

The plan covers crowns, bridges and dentures only for restorative purposes or to replace missing teeth. These services are not covered because of periodontal disease, malocclusion or other reasons.

12. Treatment of unmanageable children or otherwise unruly patients. An attempt will be made to treat all patients. However, if a patient is untreatable by virtue of apprehension or any other reason, and is referred to another office for treatment, the responsibility for payment lies with either the patient or with the parents of the patient.

Enrollees in the managed care plan must be treated by participating dentists in order to be covered. If patients receive treatment from a non-participating dentist for any reason, neither the company nor its providers are responsible for such treatment. If patients need to be treated by private dentists, they should select a standard type of plan that allows benefits at any location.

13. Services not listed in the Schedule of Benefits are not covered.

For reimbursement type plans that are based on a Schedule of Allowances, only those services actually listed in the brochure or the contract are covered. For reimbursement plans that use percentages of Usual, Customary & Reasonable fees as their basis, other services may be covered.