400N Enrollment Form - Dental Alternatives Insurance Services Inc

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Code D3330 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3920 Service Root canal - molar, per tooth (excluding final restoration) Apexification/recalcification - initial visit Apexification/recalcification - interim visit Apexification/recalcification - final visit Apicoectomy/periradicular surgery - anterior Apicoectomy/periradicular surgery - bicuspid, 1st root Apicoectomy/periradicular surgery - molar, 1st root Apicoectomy/periradicular surgery - each additional root Retrograde filling - per root Root amputation - per root Hemisection - including root removal (excluding root canal therapy) Periodontics D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant D4341 Periodontal scaling and root planing - four or more teeth - per quadrant D4342 Periodontal scaling and root planing - one to three teeth, per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report D4910 Periodontal maintenance procedures - following active periodontal therapy Initial perio charting for moderate to advanced cases Co-payment When Services Performed by Contracted General Dentist $250 $12 $12 $12 $125 $125 $125 $125 $30 U&C • Procedures noted with * are subject to a six month waiting period. D5110 D5120 D5130 D5140 Complete upper denture* Complete lower denture* Immediate upper denture* Immediate lower denture* $275 $275 $330 $330 SM-400N-IDP-SOB Customer Service (800) 880-1800 1/09 U&C $90 $30 $250 $200 $45 $36 $45 $40 $45 $5 Co-payment When Services Performed by Contracted Specialist • • • • • • • • • • • $80 • • • • $64 • • $55 • Removable Prosthodontics • Removable Prosthodontics - Includes all adjustments for up to six (6) months post-delivery. • • •
Code D5211 D5212 D5213 D5214 D5225 D5226 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851 Service Upper partial - resin base (including clasps, rests and teeth)* Lower partial - resin base (including clasps, rests and teeth)* Upper partial - cast metal base with resin saddles (including clasps, rests and teeth)* Lower partial - cast metal base with resin saddles (including clasps, rests and teeth)* Maxillary partial denture - flexible base (including any clasps, rests and teeth)* Mandibular partial denture - flexible base (including any clasps, rests and teeth)* Adjust complete denture - upper Adjust complete denture - lower Adjust partial denture - upper Adjust partial denture - lower Repair broken complete denture base Replace missing or broken teeth Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth - per tooth Add tooth to existing partial denture Add clasp to existing partial denture Rebase complete upper denture Rebase complete lower denture Rebase upper partial denture Rebase lower partial denture Reline complete upper denture (chairside) Reline complete lower denture (chairside) Reline upper partial denture (chairside) Reline lower partial denture (chairside) Reline complete upper denture (laboratory) Reline complete lower denture (laboratory) Reline upper partial denture (laboratory) Reline lower partial denture (laboratory) Interim partial denture - upper Interim partial denture - lower Tissue conditioning - upper Tissue conditioning - lower Co-payment When Services Performed by Contracted General Dentist $215 $215 $275 $275 $215 $215 $8 $8 $8 $8 $30 $22 $28 $44 $44 $22 $22 $50 $75 $75 $75 $75 $33 $33 $33 $33 $70 $70 $70 $70 $80 $80 $20 $20 • Procedures noted with * are subject to a six month waiting period. D6210 Pontic - cast high noble metal* D6211 Pontic - cast predominantly base metal* D6212 Pontic - cast noble metal* $240 $180 $220 Co-payment When Services Performed by Contracted Specialist • • • • • • • • • • • • • • • • • • • • • • • Fixed Prosthodontics • 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). • 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: Code Crowns • Cost of Noble or Hi
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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