Members and their dependents are eligible for reimbursement for dental expenses in accordance with the Fund’s established Schedule of Dental Benefits.

Active Level members, Active COBRA or “Self-Pay” Enhanced Retire Plan members are covered with maximums, per eligible member or dependent of:

• Unlimited Maximum for General Dentistry
• Unlimited Maximum for Periodontal Treatment
• 2 Implants Covered Per Year
• $1,995 Lifetime for Orthodontics, Adolescent and Adults with a $1,000 co-pay for in-network providers. (Adult and Adolescent Orthodontia Update – June 2016)

Benefit Description for Active SPERP & Cobra Members

“No-Cost” Basic Retiree Members

and their dependents are limited to an Dental maximum annually of:

$750 per family, $500 per individual for all dental services.

Dental Plan is Administered by a Third-Party Administrator for “No-Cost” Basic Retirees

A third-party administrator is a firm that is hired by the Fund to process and pay claims.  In 2021, Healthplex was hired by the Fund to streamline the Fund’s Dental claims, increase our In-Network Provider List and save money. Healthplex , Inc. is not our insurance company. The Benefit Fund remains financially responsible for your covered benefits.

Healthplex administers the dental plan adopted by the Fund’s Board of Trustees. As our third-party administrator, Healthplex reviews all Fund dental claims to insure payments are made according to the guidelines set by the SCME Benefit Fund.

Making Claim for an In-Network Dental Provider:

Making a claim with an In-Network Dental provider will be handled between the participating dentist and Healthplex.  The member or their eligible dependent simply needs to sign the claim form at the dental office.

Making a Dental Claim for Out-of Network Dentists:

Request a claim form from your worksite (payroll representative), dentist’s office or print them directly from our website. All sections must be completed, including your original signature and the current date placed where indicated when you are utilizing the services of a non-participating provider. The dentist’s signature and tax identification number must be contained on all claim forms, regardless of their status with the Fund.

Predetermination Request

If the procedure or series of treatments is a covered procedure, clinically necessary and is expected to be over $1,000, you must have your dentist file for a predetermination BEFORE the work is done. Payment for such treatment, without this determination will be subject to a fine of $250.

Please return Predeterminations and Out-of-Network claim forms, signed and dated to:

UnitedHealthcare
P.O. Box 30567 Salt Lake City, UT 84130-0567

Please note: Incomplete claim forms will be returned to you for more information, which may cause a delay in your benefit payment.

Predetermination Of Dental Benefits

Your Benefit Fund dental program has a Pre-determination of Benefits requirement for any plan of treatment and/or service submitted by a provider that is equal to or exceeding $1,000.  In addition, all periodontal and orthodontia services must be pre-determined, regardless of who is providing the service. You are responsible for advising your dentist of this requirement.  The pre-determination must be accompanied by a properly mounted set of diagnostic quality x-ray films and any other pertinent documentation that may be deemed necessary to adequately make a review for available benefits. The failure to submit for the required pre-authorization will result in a forfeiture of benefits.

Predetermination allowances are payable only after the following conditions are applied.

1. The claimant must be eligible for benefits when the described services are incurred. In the case of termination from the Fund, an expense is incurred when the service is performed, except in cases of:
   1. Dentures, or fixed bridgework – when the final impression is taken;
   2. Crown work – when preparation of the tooth is begun;
   3. Root canal therapy – when root canal treatment is completed.
2. So long as there has not been a change in the plan of benefits prior to performance of the service that would thus vary the allowance indicated.
3. So long as the total benefit payments for all treatment of a patient in any benefit period does not exceed plan maximums.
4. The allowances may be reduced by Coordination of Benefits, if applicable, to each patient.

The Benefit Fund shall have the right to request that a member or his/her dependent undergo an oral examination to verify treatment recommended in a Predetermination review, or following treatment to determine the extent of services rendered. This requirement applies where clarifying information can only be obtained in this way. Failure to comply will result in forfeiture of benefits.

Periodic Review of Treatment

The Fund reserves the right to examine dental patients to assure that in all cases proper care, procedures and costs have been assigned. It periodically reviews prescribed courses of treatment in individual cases to determine whether the Alternate Benefit Provision should be authorized and payments limited accordingly.

Alternate Benefit Provision

If an alternate benefit can be provided, giving consideration to professionally acceptable alternate procedures, services, or courses of treatment, the Fund will determine the amount of benefits payable, that would accomplish the desired results. (The attending dentist and the patient may proceed with the original treatment plan regardless of the Fund’s benefit determination.)

For example, a payment for a crown will not be allowed if an acceptable professional result can be obtained by placing a filling in the tooth. A payment will be made as if a filling was placed in the tooth that received the crown. Upon presentation of documentation satisfactory to the Fund that the tooth can only be restored by a crown, payment will be made for a crown.

The Fund retains the right to limit the number of payments to be made for dental services in circumstances that, in the Fund’s sole judgment, require such limitation.

Participating Dental Program

The Fund has made arrangements with many local dentists who have agreed to accept the fees listed in this booklet as payment in full. Should you decide to use one of the participating dentists, no charges will be made for any of the eligible dental services listed and payments will be made directly from the Fund to your dentist.  There are some exclusions. Please contact the Fund for more information. Frequency limits and general exclusions remain the same no matter which dentist (participating or otherwise) you might choose.

Participating dentists may charge you for services not listed in the Schedule of Dental Benefits, but such services should be infrequently encountered, if at all.

Please refer to the list of participating dentists for those offices accepting the Fund plan. Dentists who specialize in orthodontia, periodontia, endodontia or oral surgery are listed separately from general dentists. This list will be revised from time to time by the Fund so check with the Fund office to verify the status of the provider you have chosen.

Schedule of Benefits

Maximum Amount Payable

Active Level members, Active COBRA or “Self-Pay” Enhanced Retire Plan members are covered with an maximums, per eligible member or dependent of:

Unlimited Maximum for General Dentistry

Unlimited Maximum for Periodontal Treatment

$1,995 Lifetime for Orthodontics, Adolescent and Adults. With a $1,000 co-pay for in-network providers.

Retirees have an all-inclusive annual maximum of $750 per family, $500 per individual.

General Limitation of Covered Expenses

Covered dental expenses will not include, and no payments will be made for, expenses incurred for the performance of any dental service not provided for in this schedule. In special instances, the Fund Trustees may agree to accept certain expenses as covered dental expenses. To submit the expenses to the Fund for consideration, the dental service should be identified in terms of the American Dental Association Uniform Code of Dental Procedures and Nomenclature (codes for covered services listed in following schedule) and by narrative description. If expenses incurred for a dental service not expressly provided for in this Schedule are accepted by the Fund, the covered dental expense for that dental service will be determined while remaining consistent with those

listed in this Schedule and will be conclusive and binding. In any event, expenses incurred for instruction for plaque control, oral hygiene instruction, bite registrations, or for dental services, that do not have uniform professional endorsement, will not be accepted by the Benefit Fund as covered dental expenses.

A temporary dental service will be considered an integral part of the final dental service rather than a separate service. The Fund will not absorb or be responsible for any fees or charges that are owed by a member that exceed the benefits herein.

The Fund reserves the right to request and receive any additional information it deems necessary to properly adjudicate the claim.

GENERAL EXCLUSIONS FROM BENEFITS FOR DENTAL SERVICES

As a guide to members in their utilization of the Dental Benefit Plan, the following list specifies but does not limit the particular and general exclusions from the plan.

Payment will not be made for any expenses incurred:

1. For any services, supplies, or treatment not prescribed by a legally qualified dentist or physician;
2. For services rendered prior to the patient becoming eligible for benefits;
3. For any dental or surgical procedure performed solely or substantially for cosmetic reasons;
4. For procedures, restorations, or appliances performed or fabricated solely for cosmetic purposes or to increase vertical dimension, or to restore occlusion;
5. For replacement of an existing crown, inlay, onlay, fixed bridge, or complete or partial removable denture until five years have elapsed from the date the service was originally completed and only if the crown, inlay, onlay, fixed bridge, or complete or partial removable denture being replaced is unsatisfactory and cannot be made satisfactory;
6. For multiple abutting of teeth for prosthetic purposes when the additional teeth are free of decay and functionally sound, or for prosthetic appliances, fixed or removable, placed for the purpose of periodontal splinting;
7. For charges for temporary crowns (unless tooth is fractured, and only on anterior teeth), or for temporary dental services which will be considered an integral part of the overall dental service rather than a separate service;
8. For dental service performed by a dentist in which the Fund experiences an instance of unsatisfactory documentation or recording of services that is deemed detrimental to the Fund or the patient.
9. All periodontal treatment must be reviewed and approved for benefits prior to treatment. The most inclusive periodontal service includes all related services performed on the same date in the same area and payment will be made for the all-inclusive service only. For osseous surgery (ADA code 4260) and gingivectomy (ADA code 4210) performed on the same date, payment will be made for the all-inclusive osseous surgery.
10. For any benefit that is claimed after a period that exceeds one year from the calendar year in which dental services were rendered,
11. For replacement of a lost, stolen or missing appliance or prosthetic device or the fabrication of a spare appliance or device;
12. For dental supplies or services rendered for injuries or conditions compensable under Worker’s Compensation, Employer’s Liability laws, or “no fault” automobile insurance laws; dental services provided by a Federal or State or Provincial government agency, i.e., Veteran’s Administration Hospital, or provided without cost to the covered individual by any municipality, county, or political subdivision or community agency, except to the extent that such payments are insufficient to pay for the applicable eligible dental benefits contained in this plan;
13. For dental supplies or services furnished by or for the United States Government or any local governmental agency or where reimbursement is made elsewhere;
14. For services where a charge is not incurred or payment is not required;
15. For dental services or supplies not listed or not consistent with the Schedule of Dental Benefits unless the Fund reviews the services and accepts the expenses as Covered Dental Expenses. The Covered Dental Expense for such services will be determined by the Fund and will be consistent with those listed in the Schedule;
16. For treatment of disturbances of the temporomandibular joint, or myofacial pain;
17. For treatment that does not meet currently accepted standards of dental procedures, or treatments that are experimental in nature;
18. For orthodontic services provided when no severe malocclusion and/or functional problem exist;
19. For analgesics (such as nitrous oxide) or other euphoric or prescription drugs; local anesthesia, or drugs that desensitize teeth;
20. For any charges for broken appointments or completion of claim forms;
21. For any charges for hospitalization, including hospital visits, laboratory tests and/or laboratory examinations; all other services and treatments not specifically listed as included in the Benefit Fund’s dental plan.

NOTE: Further information is available upon request. If you have any questions regarding the coverage, benefits or exclusions, please contact the Fund Office at (631) 319-4099.