LIMITATIONS AND EXCLUSIONS OF BENEFITS

 

LIMITATIONS

  1. In all cases where the patient selects a more extensive plan of treatment than is customarily provided, the more expensive plan of treatment is considered OPTIONAL.
  2. Prophylaxis limited to one treatment in any six months.
  3. Member(s) can change providers which will become effective the first day of the following month after the requested change was received in writing by DMS.  If you are seen in an office without first notifying DMS in writing and waiting for the change to become effective, the member(s) will not be covered for those visits.
  4. If you have a balance with your current provider’s office, you will not be allowed to change providers until the balance is paid in full.  Again, if you are seen in another office your visit will not be covered and DMS will not be responsible for any charges incurred as a result.
  5. If member has dependent(s), everyone must go to the same office.  There are NO EXCEPTIONS.
  6. Full Upper and/or Lower Dentures are not to exceed one each in any five year period.  Replacement will be provided by DMS for an existing denture only if it is unsatisfactory and cannot be made satisfactory.
  7. Partial Dentures are not to be replaced with-in any five-year period unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible.
  8. Denture relines are limited to one during any 12 consecutive months.
  9. Periodontal treatments (root planning/sub gingival curettage) are limited to five quadrants during any 12 consecutive months.
  10. Bitewing x-rays are limited to not more than one series of four full films in any 12 month period.
  11. Full mouth x-rays are limited to one set every 36 consecutive months.
  12. Sealants are limited to non-carious, non-restored permanent first and second molars only to age 14 and when not covered by medical.
  13. No reimbursement shall be made for the cost of services secured from any other health care provider other than the member’s provider.
  14. Posterior composites are covered subject to the difference in cost between and amalgam and composite filling.
  15. When Benefits are payable from other sources (i.e.  Spouses coverage/or medical coverage), DMS will always be considered SECONDARY.
  16. Prior Missing teeth only covered after 12 months.

 

EXCLUSIONS

  1. Dentist services received from any dental provider outside of the DMS Dental Network, unless expressly authorized in writing by DMS are not covered.
  2. General Anesthesia and the services of special anesthesiologists.
  3. Cosmetic and Pediatric dental care.
  4. Failure to keep a scheduled appointment without the proper 24-hour notification/cancellation of said appointment will result in an office fee to be determined by the respective office and paid for completely by the member.
  5. If you change your dental provider and wish to have your records transferred to your new provider, the dentist has the right to charge a fee for your records and/or x-rays.
  6. Dentist and/or DMS reserve the right to refuse any patient/dependents that are deemed uncooperative by the office(s).
  7. Dental conditions arising out of and due to enrollee’s employment or for which Worker’s Compensation is payable. 
  8. Services which are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, county or other subdivision.
  9. Treatment required by reason of war.
  10. Dental services performed in a hospital and related hospital fees.
  11. Treatment of Fractures and Dislocations.
  12. Loss or theft of fixed and removable prosthetics (crowns/bridges/full or partial dentures).
  13. Dental expenses incurred in connection with any dental procedures started after termination of eligibility of coverage.
  14. Any service that is not specifically listed as a covered expense.
  15. Dental expenses incurred in connection with any dental procedure started prior to enrollee’s eligibility date with the DMS program.  Example: teeth prepared for crowns, root canals in progress, orthodontic treatment.
  16. Congenital Malformations
  17. Cysts and Malignancies.
  18. Dispensing of drugs not normally supplied in dental office.
  19. Accidental injury.  Accidental injury is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of benefits.
  20. Cases which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained or where the prognosis is poor or guarded.
  21. Dentist services received from any dental office other than the assigned dental office, unless expressly authorized in writing by DMS or as cited under “Out of Area Emergency Treatment”
  22. Prophylactic removal of impaction (asymptomatic non-pathological).
  23. “Specialist consultations” for non-covered benefits.
  24. Implant placement or removal, appliances placed on or services associated with implants.
  25. Extensive treatment plans involving 10 or more crowns or units of fixed bridgework are considered full mouth reconstruction and are not benefits covered of the DMS program.
  26. No coverage for Night Guards and TMJ.
  27. Treatment of Root Canals performed prior to eligibility date.
  28.  Apicoectomies and other Endodontic treatment performed on a tooth that has had a prior root canal done by a non-network dentist or performed while patient was not covered under the DMS program.
  29. DMS assumes no responsibility or liability for services performed by affiliated dentists.
  30. Any procedure presenting unusual circumstances requiring additional cost, the additional cost is not covered and is the responsibility of the patient.

 

ORTHODONTIC LIMITATIONS

  1. Orthodontic treatment must be provided by a DMS Orthodontist.
  2. Plan benefits cover 24 months of usual and customary orthodontic treatment.
  3. Should the Enrollee’s coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving an orthodontic treatment, the Enrollee and not DMS will be responsible for the payment of the balance due for treatment provided after cancellation or termination.  In such a case, the Enrollee’s balance or payments shall be determined by dividing the UCR fee in effect at the time treatment was initiated by the total number of months of active treatment and prorated for the number of months remaining to completion of the treatment.  Such amount will be payable by the Enrollee on such terms and conditions as are arranged between the Enrollee and the orthodontist.  In no instance shall the total case fee exceed the normal UCR in effect at the time treatment was initiated.
  4. Start-up fees cover the initial examination, diagnosis, consultation and treatment to two years maximum.  This includes initial construction, placement and adjustments to retainers and office visits for a maximum period of two years.
  5. If the treatment is not required or the enrollee chooses not to start treatment after diagnosis and consultation has been completed by the orthodontist, the Enrollee will be charged a consultation fee of $50 in addition to diagnostic record fees.

 

ORTHODONTIC EXCLUSIONS

  1. Pre-treatment, mid-treatment and post-treatment records which may include cephalometric x-rays, tracings, photographs and study of models.
  2. Lost, stolen or broken orthodontic appliances.
  3. Re-treatment of orthodontic cases.
  4. Changes in treatment necessitated by an accident of any kind.
  5. Surgical procedures incidental to orthodontic treatment.
  6. Surgical procedures related to a client’s condition of Micrognathia or Macrognathia.
  7. Myofunctional Therapy.
  8. Treatment related to Temporomandibular Joint Dysfunction (TMJ) and/or hormonal imbalances.
  9. Malocclusions which are so severe so that they are not amendable to ideal orthodontic therapy.
  10. Treatment that extends beyond the 24 months point of banding dentition will be subject to an office visit charge.
  11. Restorative work caused by orthodontic treatment.
  12. Phase 1* orthodontics is an exclusion as well as activator appliance and minor treatment for tooth guidance and/or arch expansion.
  13. Extractions solely for the purpose of orthodontics.
  14. Treatment in progress at inception of eligibility into the DMS program.
  15. InvisalignTreatment

 

*Phase 1 is defined as early treatment including interceptive orthodontia prior to the development of late mixed dentition.

 

Important notice: The DMS Dental program does not constitute dental insurance and is not a Health Maintenance organization contract. DMS does not reimburse the affiliated dentist or reimburse the member for the cost of dental services received by the member

 

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