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Manual of Benefits
The Supplemental Benefit The Periodontic Benefit Preauthorization General Provision Services Not Provided Home |
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COMET MARKETS PART TIME EMPLOYEES |
PAYMENT OF BENEFITS Benefits will be provided for Eligible Dental Services when billed by the licensed Dentist in charge of the case. Unless otherwise indicated, payment will be made whether services are performed in or out of the hospital. Payment for services performed by a Dentist will be made to the Dentist on the basis of the Prevailing Fee Allowance (whichever is lower). Should the Contract call for a payment of less than 100 percent Prevailing Fee, any balance will be the Employee-Subscriber's responsibility. Unless otherwise indicated, payment for all services provided under this Program will be limited to $500.00 maximum per person per year. THE BASIC PROGRAM (100% Prevailing Fee) This is the foundation of the dental care program and is required because it meets basic needs before they become major problems. Eligible procedures consist of diagnostic, preventive and restorative services - all essential to good dental health. 1. Routine oral examinations and prophylaxis (including cleaning, scaling and polishing of teeth), but not more than once in any period of six (6) consecutive months. 2. Periapical and bitewing x-rays as required. 3. Full mouth x-rays, but not more than once in any period of thirty-six (36) consecutive months, unless special need is shown. 4. Topical application of Fluoride for children under age 19. 5. Repair to broken dentures. 6. Space maintainers (not made of precious metals) that replace prematurely lost teeth for children under 19 years of age. 7. Palliative emergency treatment for dental pain. 8. Simple extractions. 9. Amalgam, silicate, acrylic, synthetic porcelain, and composite filling restorations to restore diseased or accidentally broken teeth. Gold foil restorations are not eligible. 10. Endodontics, including pulpotomy, pulp capping and root canal treatment. 11. Anesthetic services performed by (or under the direct personal supervision of) and billed for by a Dentist other than the operation Dentist or his assistant in connection with the performance of covered oral surgical services. Anesthetic services consist of the administration of an anesthetic agent or an anesthetic drug by injection or inhalation. The administration of a local infiltration or block anesthetic is not covered. 12. Consultations, limited to one consultation per consultant during any one period of hospitalization, when the subscriber is an inpatient and his dental condition requires such consultation. |