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IMPORTANT
INFORMATION REGARDING
THIS DENTAL FEE SCHEDULE LEGEND
The dental
enrollment record at the Fund office determines the way in which dental benefits
(Participating or Non Participating) are paid for the participant and his or her
eligible dependents. To verify enrollment, please contact the Fund office.
Participating Dentists may check the appropriate monthly eligibility listing.
For specific benefit information, including program restrictions, limitations and/or yearly maximums,
please refer to the participant’s Summary Plan Description (“SPD”), or you may contact the Fund office.
Fund Value
Fund "value" for
service/procedure listed
Fund Payment
Amount paid by the Fund to a Participating
Dental Plan Network Dentist
Patient Co-Payment
Patient's co-payment amount to
be collected by, and paid directly to the Participating Dental Plan
Network Dentist
Par Ped Allowance
Amount paid by the Fund for
services listed as "CAP" (capitated) AND rendered by a
Participating Dental Plan network "Pediatric" Specialist.
Non Par Payment
Amount paid by the Fund for
service for those participants who did not select and/or enroll with a
Participating Dental Plan Network Dentist.
CAP
Service is a "Schedule A" capitated procedure -
no Fund allowance paid, nor patient payment.
CAP +
Service is a "Schedule A" capitated procedure -
no Fund allowance, but patient co-payment is to be
collected.
BR
Service is evaluated "by written report" for
services rendered, including Fund and patient payment, and eligibility
status.
NC
Service is not covered under the Dental Plan.
For additional information, refer to the SPD booklet, or contact the
Fund office. Dentist may bill patient for his/her regular fee for
service rendered.
NCS
Non billable service, but is a part of "capitated"
service.
R
Restrictions and/or limits apply - refer to the
SPD "Dental Section."
Dental
Fee Schedule