400N Enrollment Form - Dental Alternatives Insurance Services Inc

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Code D6240 Pontic - porcelain fused to high noble metal* $310 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $480, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6241 Pontic - porcelain fused to predominantly base metal* $250 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $420, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6242 Pontic - porcelain fused to noble metal* $290 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $460, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6750 Crown - porcelain fused to high noble metal* $310 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $480, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6751 Crown - porcelain fused to predominantly base metal* $250 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $420, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6752 Crown - porcelain fused to noble metal* $290 • • The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth is $460, including any applicable porcelain co-payment. • Elective procedures are not subject to the six month waiting period. D6780 $240 • D6781 $180 • D6782 $220 • D6790 $240 D6791 $180 D6792 $220 D6930 $20 • D6970 $50 • D6972 D6973 Service Crown - 3/4 cast high noble metal* Crown - 3/4 cast predominantly base metal* Crown - 3/4 cast noble metal* Crown - full cast high noble metal* Crown - full cast predominantly base metal* Crown - full cast noble metal* Recement bridge Post and core in addition to fixed partial denture retainer, indirectly fabricated Prefabricated post and core in addition to bridge retainer Core build up for retainer, including any pins Co-payment When Services Performed by Contracted General Dentist $30 $30 Co-payment When Services Performed by Contracted Specialist • Oral Surgery D7111 D7140 D7210 D7220 D7230 D7240 Extraction, coronal remnants - deciduous tooth Extraction - erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth Extraction - removal of impacted tooth - soft tissue Extraction - removal of impacted tooth - partially bony Extraction - removal of impacted tooth - completely bony $14 $15 $25 $40 $60 $75 $30 $40 $70 $110 $135 $160 SM-400N-IDP-SOB Customer Service (800) 880-1800 1/09
Code D7250 D7510 D7530 D7550 D7910 D7960 D7963 D7970 Service Surgical extraction - removal of residual tooth roots Incision and drainage of abscess - intraoral soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Partial ostectomy/sequestrectomy for removal of non-vital bone Suture of recent small wounds up to 5 cm Frenulectomy (frenectomy or frenotomy) - separate procedure Frenuloplasty Excision of hyperplastic tissue, per arch Co-payment When Services Performed by Contracted General Dentist $25 U&C U&C U&C U&C $50 $50 U&C Co-payment When Services Performed by Contracted Specialist • • • • • $50 $50 • Orthodontics D8030 D8040 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8693 Adjunctive General Services D9110 D9120 D9215 D9310 D9430 D9440 D9450 D9930 D9941 Limited orthodontic treatment of the adolescent dentition (child) Limited orthodontic treatment of the adult dentition (adult) Comprehensive orthodontic treatment of the adolescent dentition (up to 24 months) (child) Comprehensive orthodontic treatment of the adult dentition (up to 24 months) (adult) Minor treatment to control harmful habits - removable appliance therapy Minor treatment to control harmful habits - fixed appliance therapy Pre-orthodontic treatment visit Periodic orthodontic treatment visit (as part of contract) Retention phase (removal of appliances, construction and placement of retainers) Rebonding or recementing; and/or repair, as required of fixed retainers Palliative (emergency) treatment of dental pain - minor procedure Fixed partial denture sectioning Local anesthesia Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (other than orthodontist) Office visit for observation (during regularly scheduled hours) - no other services performed Office visit - after regularly scheduled hours Case presentation, detailed and extensive treatment planning Treatment of complications (post-surgical) - unusual circumstances, by report Fabrication of athletic mouthguard U&C U&C U&C U&C $75 $95 U&C $0 U&C U&C $15 U&C $0 $50 $5 $30 $5 U&C $140 $1,450 $1,550 $2,100 $2,250 • • $45 $0 $175 $0 $15 • $0 $50 • • $5 $0 • SM-400N-IDP-SOB Customer Service (800) 880-1800 1/09
Page 1 and 2: Dental HMO SmileSaver Individual 40
Page 3 and 4: SmileSaver dental and vision plans
Page 5 and 6: DIRECT REFERRAL DENTAL PLAN* Diagno
Page 7 and 8: Code Crowns • Cost of Noble or Hi
Page 9: Code D5211 D5212 D5213 D5214 D5225
Page 13 and 14: Dental Terminology Definitions Thes
Page 15 and 16: Principle Exclusions and Limitation
Page 17 and 18: Principle Exclusions and Limitation
Page 19 and 20: Evidence of Coverage and Disclosure
Page 21 and 22: Who May Enroll You may enroll yours
Page 23 and 24: SmileSaver Individual & Family Enro
Page 25 and 26: Uniform Health Plan Benefits and Co
Page 27 and 28: No co-payment is required for a sec
Page 29 and 30: prescribed time, the member must ma
Page 31 and 32: • Failure to establish a satisfac
Page 33 and 34: TDD number for the hearing impaired
Page 35 and 36: The following definitions are used
Page 37 and 38: SAFEGUARD DENTAL & VISION HIPAA NOT
Page 39 and 40: Information to a coroner or medical
Page 41 and 42: electronically). The first list you
Page 44 and 45: 000685723/3297-CA-DAIS-CDT9KIT-1
Page 46: SM-DHMO-C

400N Enrollment Form - Dental Alternatives Insurance Services Inc

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