400N Enrollment Form - Dental Alternatives Insurance Services Inc

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Code D0210 D0220 D0230 D0240 D0270 D0272 D0273 D0274 D0330 D0460 D0470 Service Office visit - per visit (including all fees for sterilization and/or infection control) X-rays intraoral - complete series - including bitewings (not including ortho x-rays) X-rays intraoral - periapical - first film X-rays intraoral - periapical - each additional film X-rays intraoral - occlusal film X-rays bitewing - single film X-rays bitewings - two films X-rays bitewings - three films X-rays bitewings - four films X-rays panoramic film Pulp vitality tests Diagnostic casts Co-payment When Services Performed by Contracted General Dentist $0 $6 $0 $0 $0 $0 $0 $0 $0 $0 $0 $5 Co-payment When Services Performed by Contracted Specialist $0 $37 $14 $6 ••••• $25 •• • • • Preventive Services • Prophylaxis are limited to 2 per 12 months. • Fluoride treatments are limited to 2 per 12 months for children under age 18. • Space maintainers are limited to children under age 14. D1110 D1120 D1203 D1206 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D1555 Restorative Treatment D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2394 Prophylaxis - adult Prophylaxis - child Topical application of fluoride (excluding prophylaxis) - child Topical fluoride varnish; therapeutic application for moderate to high caries risk patients Oral hygiene instructions Sealant - per tooth Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Space maintainer - removable - unilateral Space maintainer - removable - bilateral Recementation of space maintainer Removal of fixed space maintainer Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle, anterior Resin-based composite, one surface, posterior Resin-based composite, two surfaces, posterior Resin-based composite, three surfaces, posterior Resin-based composite, four or more surfaces, posterior $15 $10 $5 $5 $0 $10 $40 $80 $40 $90 $10 $10 $11 $17 $27 $30 $24 $30 $36 $42 $73 $103 $121 $149 • • • • • • • • • • • SM-400N-IDP-SOB Customer Service (800) 880-1800 1/09
Code Crowns • Cost of Noble or High Noble Metal (gold, etc.) is included in the co-payments shown. • There is an additional $145 co-payment per crown/bridge unit in addition to regular co-payments for porcelain on posterior teeth (molars or bicuspids). • Procedures noted with * are subject to a six month waiting period. D2750 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. D2751 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. D2752 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. D2780 $240 • D2781 $180 • D2782 $220 • D2790 $235 • D2791 $175 • D2792 $215 • D2910 D2915 D2920 D2930 D2931 D2940 D2950 D2951 D2952 D2954 D2961 D2962 D2970 D2971 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 inlay, onlay, or partial coverage restoration Recement cast or prefabricated post and core Recement crown Prefabricated stainless steel crown - primary tooth Prefabricated stainless steel crown - permanent tooth Sedative filling Core build up, including any pins Pin retention - per tooth, in addition to restoration Post and core in addition to crown, indirectly fabricated Prefabricated post and core in addition to crown Labial veneer - resin laminate, laboratory* Labial veneer - porcelain laminate, laboratory* Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial dental framework Endodontics D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3310 Root canal - anterior, per tooth (excluding final restoration) D3320 Root canal - bicuspid, per tooth (excluding final restoration) Co-payment When Services Performed by Contracted General Dentist $14 $14 $14 $48 $48 $0 $0 $0 $50 $30 $400 $425 $0 $113 $5 $5 $15 $125 $190 Co-payment When Services Performed by Contracted Specialist 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: DIRECT REFERRAL DENTAL PLAN* Diagno
Page 9 and 10: Code D5211 D5212 D5213 D5214 D5225
Page 11 and 12: Code D7250 D7510 D7530 D7550 D7910
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

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