Member Benefits

Dental Benefits

Overview

When you need dental care, you can see any dentist you choose and the services are covered according to the chart below. For more information about dental benefits, contact the Claims Administration office.

Benefit Coverage
Preventive Care Services
  • Oral exams and routine cleanings: twice in a calendar year
  • Bitewing x-rays and fluoride applications: once per calendar year
  • Sealants and full mouth x-rays: once every three consecutive calendar years
Fund pays 100%, up to the reasonable and customary charge. There is no deductible.
Non-Preventive Services
  • Calendar Year Deductible
  • Coinsurance
  • $75 per person; $225 per family
  • Fund pays 75% of covered expenses, after deductible, up to the reasonable and customary charge.
Calendar Year Maximum Fund pays up to $750 per person per calendar year toward all covered expenses. Note: Calendar Year Maximum does not apply to pediatric oral care

Filing Dental Claims

You can seek care from any dentist you choose. When you receive dental services, be sure to ask the dentist to file a claim for you. He/she can submit all necessary claim information to the Fund’s Claims Administrator on your behalf. Any reimbursements will be sent directly to the provider. In some cases, you may have to submit a claim for benefits directly to the Fund’s Claims Administrator.

  • How to submit a claim

    If you must submit a claim for dental care received, you should:
    • Obtain an itemized bill from the dentist. An itemized bill generally includes all of the following:
    • Patient’s name and address
    • Date of Service
    • Type of Service and diagnosis
    • Itemized charges
    • Provider’s complete name, address, and tax identification number
    • Download a claim form.
    • Complete the claim form and attach the itemized bill to the form.
    • Send the claim form and bill to the address on the claim form.

    Payment for eligible benefits will be sent to the dentist unless your claim includes a paid receipt. If a receipt is submitted with your claim, payment will be sent to you.

    A claim is not considered filed until it is received by the Fund’s Administrative Office. The Fund’s Administrative Office will process your claim within 30 days of the date it is filed, unless special circumstances require additional processing time. If additional information is needed to process your claim, the Fund may request additional information from you or the dentist. You and/or your dentist will have at least 45 days to submit the additional information.

    When certain expenses are not eligible under the Plan, you will be notified by the Fund’s Administrative Office that the claim is denied, with an explanation of the reasons for the denial. You will receive a Notice of the Adverse Benefit Determination in writing which contains the following:

    • The specific reasons for the adverse benefit determination;
    • The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
    • A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
    • The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
    • A notice of your right to a written explanation of any exclusion which affects your claim; and
    • A description of this Plan’s Appeals Procedure.