SBF Summary Plan Handbook - CWA Local 1180

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SBF Summary Plan Description 06-11-12 Adjunctive General Services 9110 Palliative (emergency) treatment of dental pain 20.00 9220 General anesthesia – first 30 minutes 100.00 9221 General anesthesia – each additional 15 minutes 50.00 9310 Consultation 30.00 9951 Occlusal adjustment – limited 20.00 9952 Occlusal adjustment – complete 50.00 When Your Treatment Costs $500 or More If your dentist expects that your treatment will cost $500 or more, the Fund must approve your treatment before the work is done. In such case, your dentist must submit for review by the Fund’s Dental Consultant: ‣ The Proposed Treatment Plan and ‣ Supporting X-rays. After review, you and your dentist will be told: ‣ What treatment will be covered ‣ What the Fund estimates it will pay. The Fund reserves the right to deny claims amounting to $500 or more which have not been reviewed by the Fund’s Dental Consultant before treatment begins. If the Fund is the secondary plan, pre-treatment review by the Fund’s Dental Consultant is not required where the primary plan has already performed the pretreatment review. If the primary plan has not performed a pre-treatment review, then pre-treatment review by the Fund’s Dental Consultant is required before the work is done. Following pre-treatment review, you will receive an estimate of the benefit the Fund will pay. In order to receive payment from the Fund: ‣ Treatment must be completed and ‣ A Treatment Completion form must be signed by the dentist and submitted to the Fund after the work has been performed. Pre-treatment review is not a guarantee of payment. No payment will be made if the patient is not eligible when services are rendered. 52
SBF Summary Plan Description 06-11-12 Getting Your Benefit Follow these simple steps: ‣ Obtain the official Local 1180 Dental Claim Form from the Fund Office. ‣ Complete the patient and subscriber/employee sections and sign the form in box #39 after you have discussed the treatment plan and associated fees with your dentist. Only if you wish to assign payment directly to your dentist, also sign box #41. ‣ If the total charges for the treatment are expected to be $500 or more, have your dentist submit a Pre-Treatment Estimate form and your x-rays to the Fund’s Dental Consultant. When the Pre-Treatment Estimate form is returned to your dentist with information about the benefits payable for your treatment, review these benefits with the dentist before work begins. ‣ When the treatment is completed, have your dentist complete the dentist’s statement of work done. The completed form must be sent within 90 calendar days after the completion of dental treatment to: CWA Local 1180 Scheduled Dental Benefit Plan Dental Claim Office 253 West 35th Street, 12 Floor New York, NY 10001-1907 Claims submitted after the 90-day limit will be denied. IMPORTANT NOTICE The Fund does NOT recommend or endorse any particular dentist. You are responsible for selecting the dentist of your choice, whether the dentist is a “participating” or “non-participating” dentist. You should apply the same criteria and care in choosing a participating dentist that you would apply in selecting a nonparticipating one. What If I Want To Change To A Different Dental Plan The Fund offers two dental plan options. If you are enrolled in the Scheduled Dental Benefit Plan but would like to change to Dentcare, you need to follow these simple steps: 53
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SBF Summary Plan Handbook - CWA Local 1180

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