Dental Benefit

Dental Network of America (DNoA)

Lineco has an agreement with a dental preferred provider (PPO) network called the Dental Network of America (DNoA). DNoA offers a large network of participating dentists who have agreed to charge negotiated fees that are lower than what these dentists normally charge. This means you will save money on your family's dental bills when you use DNoA dentists.

HOW TO FIND A DNOA DENTIST

DNoA customer service representatives are also available to assist you in your selection of a dentist.

This is a voluntary program—you are not required to use a DNoA dentist, and your benefits won't be reduced if you use a non-participating dentist.

Payment of Dental Benefits

Predetermination of Benefits Procedure - If the dentist's charges will be $500 or more, your claim should be submitted for predetermination of benefits as explained below before any major work is started. Predetermination of benefits doesn't apply to orthodontic care.

If you don't want to follow the predetermination procedure, you can just submit your claim after the dental work is done. However, you may be unpleasantly confronted with a large, unexpected out-of-pocket cost.

When the Predetermination Procedure Is Not Necessary - Your dentist can perform oral examinations, cleanings, fluoride applications, and dental x-rays before submitting the claim for predetermination. In addition, no predetermination is necessary when the charges for a plan of treatment are expected to be less than $500 or when emergency treatment is performed.

If emergency dental treatment is performed because of an accident or other dental emergency, it won't be possible to obtain a predetermination before getting treatment. However, if the dentist must render additional non-emergency treatment in connection with the dental emergency, a predetermination of benefits claim form should be submitted by your dentist and reviewed by the Fund Office prior to such work if the charges for the additional dental services will be $500 or more. In addition, the predetermination of benefits form should be accompanied by a bill or other explanation of the emergency treatment that was rendered by the dentist.

Note - A predetermination of benefits does not guarantee payment for dental benefits. Coverage is valid only upon determination of eligibility.

Alternate Courses of Treatment - If alternate services can be used to treat a dental or orthodontic condition, covered dental expenses will be limited to the reasonable and customary (R&C) charge for that service which is most commonly used nationwide in the treatment of that condition and which is recognized by the dental profession to be appropriate in accordance with the accepted nationwide standards of dental practice. In cases where you and/or your dentist choose a more expensive level of care, any charges in excess of the R&C level as determined by this provision will not be considered covered dental expenses.

Payment of Dental Benefits - The Plan will pay 80% of a covered person's covered dental expenses each year up to a maximum benefit of $2,000. Once a person has received $2,000 in dental benefits during a year, he will not be entitled to any further dental benefits during the rest of that year.

A $100 deductible applies to covered restorative care expenses each year. If any part of a person's deductible is applied to covered dental expenses incurred during October, November, or December of a calendar year, that person's deductible for the following year will be reduced by the amount applied. The dental deductible cannot be used to satisfy any Comprehensive Benefit deductible or out-of-pocket maximum.

Date of Incurral - For payment purposes, treatment is considered to have been incurred on the date the service is rendered. However, for the following services that require more than one visit, the incurral date is considered to be: (1) for full or partial dentures, when the impression is taken for the appliances; (2) for root canal therapy, when the tooth is opened; and (3) for fixed bridgework, crowns and other gold restorations, when the tooth is first prepared.

Dental Treatment Other Than in a Dentist's Office - If a dentist recommends that a person have a dental procedure performed in a hospital (on an inpatient basis or in the hospital outpatient department) or in an outpatient surgical center, a doctor who is an M.D. or D.O. must certify the medical necessity of having the procedure performed in such a setting. The doctor must submit a letter to the Fund Office prior to the treatment which gives the medical reasons the procedure should be performed in a hospital or ambulatory surgical center instead of the dentist's office. Be sure to contact the Fund Office for advance approval of any such treatment. (If only the dentist certifies the medical necessity, or if the doctor's letter is not received before the treatment is performed, or if the Fund Office does not approve the treatment, the hospital or ambulatory surgical center expenses will not be paid.)

Covered Dental Expenses

Covered dental expenses are the reasonable and customary charges incurred by a covered person for the following services and supplies which are necessary for treatment of a dental condition.

Covered Diagnostic and Preventive Care Expenses - 80% Reimbursement (No Deductible)

  1. Routine oral examinations and prophylaxis (scaling and cleaning of teeth, including periodontal maintenance prophylaxis), up to two per calendar year.
  2. Topical application of fluoride.
  3. Space maintainers that replace prematurely lost teeth for children under 19 years of age.
  4. Emergency palliative treatment.
  5. Dental x-rays, including full mouth x-rays (once in a period of 36 consecutive months), supplementary bitewing x-rays (up to two sets per calendar year), and such other dental x-rays as are required in connection with the diagnosis of a specific condition requiring treatment.
  6. For eligible dependent children under age 15 only, sealants on the 6-year and 12-year molars only, with at least 5 years in between a repeat sealant procedure on any tooth.

(A predetermination of benefits is not necessary for diagnostic and preventive dental care.)

Covered Restorative Care Expenses - 80% Reimbursement (Subject to Deductible)

(If the charges for the following types of restorative care will be more than $500, you should follow the Predetermination of Benefits Procedure on page 65).

  1. Extractions.
  2. Oral surgery.
  3. Amalgam, silicate, acrylic, synthetic porcelain, and composite filling restorations to restore diseased or accidentally broken teeth.
  4. General anesthetics when medically necessary and administered in connection with oral surgery.
  5. Treatment of periodontal and other diseases of the gums and tissues of the mouth.
  6. Endodontic treatment, including root canal therapy.
  7. Injection of antibiotic drugs by the attending dentist.
  8. Dental implants to anchor a full denture, or implantation of a single tooth when approved by the Fund's dental consultant. If the implantation procedure is begun in one calendar year and completed in another, the combined charges will be subject to the maximum benefit for the year in which the procedure was begun. (If a restoration such as a crown is placed on an implant, the charge for the restoration is considered a separate procedure.)
  9. Repair or cementing of crowns, inlays, onlays, bridgework or dentures; or relining or rebasing of dentures more than six months after the installation of an initial or replacement denture, limited to one relining or rebasing in any period of 36 consecutive months.
  10. Inlays, onlays, gold fillings, or crown restorations to restore diseased or accidentally broken teeth, but only when the tooth, as a result of extensive caries or fracture, cannot be restored with an amalgam, silicate, acrylic, synthetic porcelain, or composite filling restoration.
  11. Initial installation of fixed bridgework (including inlays and crowns as abutments).
  12. Initial installation of partial or full removable dentures (including precision attachments and any adjustments during the 6-month period following installation).
  13. Replacement of an existing partial or full removable denture, fixed bridgework, an inlay, an onlay or a single crown by a new denture, bridgework, inlay, onlay or crown, or the addition of teeth to an existing partial removable denture, but only if satisfactory evidence is presented that:
    1. The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed; or
    2. The existing denture is an immediate temporary denture which cannot be made permanent and replacement by a permanent denture takes place within 12 months from the date of initial installation of the immediate temporary denture; or
    3. The existing denture, bridgework, inlay, onlay or single crown cannot be made serviceable and, if it was installed and paid for under this Dental Benefit, at least 5 years1 have elapsed prior to its replacement.

Normally, dentures will be replaced by dentures, but if a professionally adequate result can be achieved only with bridgework, charges for such bridgework will be included as covered dental expenses.

Denture work performed by licensed denturists will be covered in those states which license denturists.

Covered Orthodontia Expenses - 80% (No Deductible) - FOR CHILDREN ONLY

Orthodontia benefits are payable for dependent children ONLY, and the benefits paid for orthodontia do not apply to the child's Dental Benefits maximum. The Plan could pay $2,000 of regular Dental Benefits in a year plus $2,000 of orthodontia benefits in that same year. However, once the lifetime orthodontia maximum has been paid, the Plan will not pay any additional orthodontia benefits for that child.

The Plan will pay 80% of the reasonable and customary (R&C) charges incurred for orthodontic treatment for each of your covered dependent children up to a lifetime maximum benefit of $2,000 per child. No deductible applies to orthodontia expenses. You choose your own orthodontist. However, you may get a better value from this benefit if you use an orthodontist in the DNoA network.

Also, a predetermination of benefits is not necessary for orthodontic care. You should, however, contact the Fund Office to check your eligibility for Dental Benefits. The following rules apply to orthodontia benefits:

  1. The initial payment usually required will be considered at up to 25% of the total fee within the R&C limits for the treatment plan. This includes the preliminary diagnostic work-up and initial banding. (Extractions performed as a part of an orthodontic course of treatment are considered orthodontia and are paid as such.) The balance of the charges should be billed to be paid on a quarterly basis until the treatment is completed or until the maximum allowable benefits have been received (unless the child's eligibility for Dental Benefits terminates before then). The orthodontist should submit quarterly verification to the Fund Office that a covered person's orthodontic treatment is continuing.
  2. If a child is undergoing orthodontic treatment when his eligibility starts, the Plan will pay 80% of the R&C charges that are determined to be incurred after he became eligible. The Plan will only provide reimbursement for payments for services rendered on or after the date a child's eligibility starts. No payment will be made for past due payments.
  3. There is no extension of benefits for orthodontia expenses. All benefits for orthodontia will terminate on the date that the child's eligibility for Dental Benefits terminates. No Plan payments will be made for payments that are due after the child's eligibility for Dental Benefits terminates. Benefits are only payable on the date that a payment is due the orthodontist.
  4. No payment will be made for a duplicate or for a replacement of a lost, missing or stolen orthodontic device.

Dental Exclusions and Limitations

No Dental Benefits are payable for:

  1. Treatment by other than a dentist except that scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of a dentist.
  2. Services and supplies that are cosmetic in nature, including charges for personalization or characterization of dentures.
  3. The replacement of a lost, missing, or stolen removable prosthetic device unless no benefits were paid under this Plan for that prosthetic device.
  4. Services or supplies which are for orthodontic treatment except as outlined under Covered Orthodontia Expenses.
  5. Any duplicate prosthetic device or any other duplicate appliance.
  6. Sealants, except for dependent children under age 15 as stated in No. 6 under Covered Diagnostic and Preventive Care Expenses.
  7. Oral hygiene, dietary instruction, or a plaque control program.
  8. Implantology except as specifically stated in Covered Restorative Care Expenses.
  9. Occlusal adjustments.
  10. Splints.
  11. Appliances (such as night guards) used to control harmful habits.
  12. Services performed by a denturist who is not licensed as a denturist in the state in which the services are performed.
  13. Treatment of conditions related to the temporomandibular jaw joint (TMJ).
  14. Treatment for opening of vertical dimension.
  15. Services or supplies received as a result of dental disease, defect, or injury due to war, declared or undeclared, or any act of war or aggression.
  16. Dental care or services paid for or furnished by or at the direction of any governmental agency, but only to the extent paid for or furnished.
  17. Dental procedures that are included as covered medical expenses under the Comprehensive Benefit.
  18. Prosthetic devices (including bridges and crowns), and the fitting of such devices, which are ordered while the individual is not eligible for Dental Benefits.
  19. Prosthetic devices (including bridges and crowns), and the fitting of such devices, which are ordered while the person is eligible for Dental Benefits but which are finally installed or delivered to the person more than 90 days after termination of eligibility.
  20. Treatment incurred while a person is not eligible for Dental Benefits.
    • For full or partial dentures, treatment is considered incurred when the impression is taken for the appliances.
    • Root canal therapy is considered incurred when the tooth is opened.
    • Fixed bridgework, crowns, and other gold restorations are considered incurred when the tooth is first prepared.

Extension of Dental Benefits

Dental Benefits will be available for a person for 90 days after his eligibility terminates for covered dental expenses incurred for: (1) fillings, bridgework, crowns or gold restorations, provided the tooth was prepared while the person was eligible for Dental Benefits; (2) full or partial dentures, provided the impression for the appliance was taken while the person was eligible for Dental Benefits; or (3) endodontic treatment, provided the tooth was opened for root canal therapy while the person was eligible for Dental Benefits.

Footnotes

  1. If the condition of the jaw requires medically necessary surgery so that existing dentures are no longer serviceable, the expenses incurred for denture replacement will be considered for payment regardless of the 5-year limitation stated above. However, you should contact the Fund Office before having the surgery to be sure that it is considered medically necessary. If it is not, and your dentures are replaced within 5 years of the initial installation, the Plan won't pay for the dentures.