Visa Inc. Cigna Dental Health Maintenance Organization (DHMO) Plan and and Cigna Dental PPO Plan Summary of Benefits for Retirees
Effective January 1, 2015
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Table of Contents ABOUT YOUR PARTICIPATION ................................................................................................. 1 ID Cards ........................................................................................................................................ 1 Coverage Levels ........................................................................................................................... 1 YOUR DENTAL OPTIONS ........................................................................................................... 1 HOW YOUR CIGNADENTAL DHMO PLAN WORKS ................................................................. 2 YOUR CIGNA DENTAL DHMO PLAN BENEFITS ...................................................................... 2 What to Do in an Emergency ........................................................................................................ 2 Pre-Treatment Plan....................................................................................................................... 3 What Is Covered ........................................................................................................................... 4 Preventive and Diagnostic Care ................................................................................................... 4 Restorative Care ........................................................................................................................... 4 Major Restorative Care ................................................................................................................. 5 Orthodontia ................................................................................................................................... 5 What Is Not Covered ..................................................................................................................... 5 Limitations on Covered Services .................................................................................................. 7 HOW YOUR CIGNA DENTAL PPO PLAN WORKS ................................................................... 7 YOUR CIGNA DENTAL PPO PLAN BENEFITS ......................................................................... 9 What to Do in an Emergency ........................................................................................................ 9 Pre-Treatment Plan....................................................................................................................... 9 What Is Covered ........................................................................................................................... 9 Preventive Care ............................................................................................................................ 9
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Restorative Care ......................................................................................................................... 10 Major Care .................................................................................................................................. 11 Orthodontia ................................................................................................................................. 11 What Is Not Covered ................................................................................................................... 11 CIRCUMSTANCES THAT MAY RESULT IN DENIAL, LOSS OR FORFEITURE OF BENEFITS .................................................................................................................................................... 13 ADDITIONAL RULES THAT APPLY TO THESE PLANS ......................................................... 15 Coordination of Benefits .............................................................................................................. 15 Non-Duplication of Benefits – Cigna Dental PPO Plan ............................................................... 15 Standard Coordination of Benefits – Cigna DHMO Plan ............................................................ 16 Determining Primary Coverage ................................................................................................... 16 HOW TO REACH THE PLAN .................................................................................................... 17 CLAIM PROCEDURES FOR CIGNA DENTAL PPO PLAN ...................................................... 18 Filing a Claim .............................................................................................................................. 18 Time Frame for Initial Claim Determination ................................................................................ 18 If You Receive an Adverse Benefit Determination ...................................................................... 21 Procedures for Appealing an Adverse Benefit Determination ..................................................... 22 APPENDIX A – CIGNA DENTAL PPO BENEFIT SUMMARY .................................................. 28 APPENDIX B – CIGNA DENTAL DHMO PATIENT CHARGE SCHEDULE ............................. 32
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This document summarizes the Cigna Dental Health Maintenance Organization (“DHMO”) Plan and the Cigna Dental Preferred Provider Organization (“PPO”) Plan, effective January 1, 2015, for eligible retirees. The plans are offered under the Visa Retiree Health Plan. Please refer to the SPD for the Visa Retiree Health Plan for information regarding eligibility, how to enroll, when coverage begins and ends, how to pay for coverage, making changes mid-year, your rights under ERISA and COBRA, and general administrative information. ABOUT YOUR PARTICIPATION ID Cards No cards are issued if you are enrolled in the Cigna Dental PPO Plan. After you enroll in the Cigna Dental DHMO Plan for the first time, you will receive a DHMO ID card for yourself and each newly enrolled family member. The ID cards show that you are enrolled in the Cigna Dental HMO plan. Your Network General Dentist's name and telephone number are included on the informational sleeve. Coverage Levels You may choose a different level of dental plan coverage than you do for medical plan coverage. YOUR DENTAL OPTIONS If you are a Group 1 Retiree (as defined in the SPD for the Visa Retiree Health Plan), you may choose from the following dental plan options:
Cigna Dental Health Maintenance Organization (DHMO) Plan; or
Cigna Dental Preferred Provider Organization (PPO) Plan.
If you are a Group 2 Retiree (as defined in the SPD for the Visa Retiree Health Plan), you may enroll only in the Cigna Dental Preferred Provider Organization (PPO) Plan.
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HOW YOUR CIGNA DENTAL DHMO PLAN WORKS Here is a look at how the Cigna Dental DHMO Plan dental coverage works. Dental Health Maintenance Organization (DHMO) With a DHMO, you have access to a network of dentists and other dental providers who have agreed to offer their services at predetermined rates. A DHMO works much like a Health Maintenance Organization (HMO) for medical care. You must choose a Network General Dentist when you enroll and go to this dentist when you need dental care. If you wish, you and each covered member of your family may select a different Network General Dentist. If you do not select a Network General Dentist, one will be selected for you. Please note that your Network General Dentist’s participation in the DHMO may change at any time. If this occurs, you will need to select a new Network General Dentist. Your Network General Dentist will provide all of your services, including referrals as needed to specialists such as endodontists or periodontists. You do not have to file claim forms your DHMO Network General Dentist files them for you. When you elect DHMO coverage, you pay a copayment for covered services each time you receive care. There is no deductible or annual maximum as long as you receive care from your Network General Dentist. A separate lifetime maximum applies to orthodontia services. Cigna Dental does not pay for treatment rendered by a nonnetwork dentist (except emergencies) or for services that were not authorized by Cigna Dental. YOUR CIGNA DENTAL DHMO PLAN BENEFITS Please refer to Appendix B for some commonly used services that are covered by the Cigna Dental DHMO Plan. Contact Cigna’s Member Services at 1-800-516-9104, to find out how services not listed here are covered. What to Do in an Emergency An emergency is a dental condition of recent onset and severity which would lead a prudent layperson with an average knowledge of dentistry to believe that the condition requires immediate dental procedures to control excessive bleeding, relieve severe pain
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or eliminate acute infection. The plan does not cover services provided in a hospital room, surgi-center or urgent care facility. You are covered for procedures provided in a dental office by a licensed dentist, provided they are covered under the plan and not covered under a medical plan policy or are services provided in a hospital. If you receive emergency services while you are outside of your service area or are unable to contact your Network General Dentist, you may receive emergency care for covered services as listed on your Patient Charge Schedule (schedules are available on BenefitSource), from any general dentist’s office prior approval is not required for dental emergencies. If you receive emergency care for covered services, you will be responsible for the charges listed on your Patient Charge Schedule, and Cigna Dental will reimburse you for the difference between the dentist’s usual fee for emergency covered services and your patient charge, up to $50 per incident. To receive reimbursement, you must send the appropriate reports and X-rays to Cigna Dental. Please note that the Patient Charge Schedule includes a patient charge for emergency care rendered after regularly scheduled office hours. This charge will be in addition to other applicable patient charges. Pre-Treatment Plan If you need specialist care, orthodontic care or any other dental care that is expected to cost $200 or more, we recommend that you ask your dentist to prepare a pre-treatment plan and send it to Cigna Dental. To file a pre-treatment plan, your dentist should complete a claim form he/she should omit the dates of service and identify it as a “pre-estimate” versus a claim for actual services. Once the form is complete, your dentist should return it to the address shown on the form before your care begins. You and your dentist will receive an explanation of benefits that details the benefits payable under the plan. The pre-treatment review of benefits is valid for 12 months, unless your benefits or eligibility change.
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What Is Covered A summary of services covered under the Cigna Dental DHMO Plan is listed below. For a detailed listing of covered services and the associated copayment, please refer to your Patient Charge Schedule in Appendix B. Preventive and Diagnostic Care
Oral exams, twice every calendar year
Prophylaxis (teeth cleanings), twice every calendar year
Bitewing X-rays
Full-mouth X-rays, once every three calendar years
Panoramic X-rays, once every three calendar years
Fluoride treatments for dependents up to age 19, twice every calendar year
Sealants
Fixed space maintainers
Preventive care training
Diagnostic casts
Restorative Care
Amalgam and composite/resin fillings
Root canal therapy, including X-rays, tests, exams and follow-up care related to the root canal
Osseous surgery
Periodontal scaling
Denture adjustments
Bridge recementation
Simple extractions
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Surgical removal of erupted teeth
Removal of impacted teeth
Local anesthesia, analgesic and routine postoperative care for extractions and oral surgery
General anesthesia, if medically necessary
Sedation, if medically necessary
Major Restorative Care
Crowns
Bridges
Dentures
Prosthesis over implant
Orthodontia
Orthodontic work-up, including X-rays, diagnostic casts and treatment and retention appliances
Active treatment
Fixed or removable appliances
What Is Not Covered The services listed below are not covered under your Cigna Dental DHMO Plan. If you receive care for these services, you are responsible for the full fee charged by your dentist.
Any service not listed on the Patient Charge Schedule in Appendix B
Services provided by a non-network dentist without Cigna Dental’s prior approval, unless it’s an emergency
Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws
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Services provided or paid through a federal or state government agency, political program or public program, other than Medicaid
Services required while serving in the armed forces or international authority that relates to a declared or undeclared war or act of war
Cosmetic dentistry or cosmetic dental surgery (any dentistry or surgery performed solely to improve appearance)
General anesthesia, sedation and nitrous oxide, unless medically necessary and provided in conjunction with covered services performed by an oral surgeon or periodontist
Prescription drugs (If you are enrolled in a Visa-sponsored medical plan and your dentist prescribes drugs, you will need to have your dentist contact your primary care physician for approval of the expense. Prescription drugs are not covered under the dental plans; only the medical plans provide reimbursement for prescription drugs. If your primary care physician does not approve your dentist's prescription, no prescription drug benefits will be payable.)
Procedures, appliances or restorations whose main purpose is to: Change vertical dimension Diagnose or treat abnormal conditions of the temporomandibular joint (TMJ),
unless TMJ therapy is specifically listed on your Patient Charge Schedule Restore teeth that have been damaged by attrition, abrasion, erosion and/or
abfraction
Replacement of fixed or removable appliances that have been lost, stolen or damaged due to patient abuse, misuse or neglect
Services associated with the placement, repair, maintenance or removal of a dental implant; implant abutment(s); or any services related to the surgical placement of a dental implant
Unnecessary or experimental services
Procedures or appliances for minor tooth guidance or to control harmful habits
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Hospitalization and associated incremental charges for dental services performed in a hospital
Services covered by a group medical plan, no-fault auto insurance policy or insured motorist policy
The completion of crown, bridge, denture, root canal treatment, or implant supported prosthesis (including crowns bridges and dentures) that was in progress before you were covered by the Cigna Dental HMO plan
Crowns, bridges and/or implant supported prosthesis used solely for splinting
Resin bonded retainers and associated pontics
Services for which benefits are not paid for by the Cigna Dental DHMO Plan or services not listed under the “What Is Covered” section above.
Pre-existing conditions are not excluded if the procedures involved are otherwise covered under your Patient Charge Schedule in Appendix B. Limitations on Covered Services The Cigna Dental DHMO Plan places limits on certain covered services.
The frequency of certain covered services, like cleanings is limited; refer to the Patient Charge Schedule in Appendix B for specific limitations on frequency.
You must receive payment authorization from a Network Specialty Dentist for specialty care.
The plan does not cover pediatric dentistry for children over age seven; children over age seven must receive care from a Network General Dentist.
Surgical removal of impacted wisdom teeth is only covered if the removal is required for orthodontic reasons or because the tooth is diseased.
HOW YOUR CIGNA DENTAL PPO PLAN WORKS Here is a look at how the Cigna Dental PPO Plan dental coverage works.
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Dental Preferred Provider Organization (PPO) With the Cigna Dental PPO Plan, you can receive care from a dental provider who is part of the dental plan’s network or from a dental provider outside the network. No matter where you receive care, the plan will pay a certain level of benefits. The difference is the dental plan has negotiated special discounted rates with its network providers.
When you go to a network dental provider. You will pay less overall because the cost of the service is lower than what a non-network provider might charge. That is because network dentists have agreed to provide services at negotiated rates. Plus, there are no claim forms to file; your network dentist is paid directly by the plan.
When you go to a non-network dental provider. The plan will pay benefits based on what is considered the maximum reimbursable charge (MRC) for a particular service. MRC is based on the typical amount charged by most providers in your geographic area for similar services. If the provider charges more, you will be responsible for paying the amount that exceeds the MRC, in addition to the applicable coinsurance and deductible. You will generally be asked to pay for your care at the time of your visit and submit a claim form for reimbursement.
When you elect Cigna Dental PPO Plan coverage, the plan pays 100% of the cost of preventive care. You pay a deductible and then a percentage of the cost for other dental services. There is an annual per person maximum of $2,000 for dental services and a separate lifetime orthodontia maximum of $2,000 per person for services from a Cigna Dental PPO Plan orthodontist and $1,000 per person for services from an out-ofnetwork orthodontist.
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YOUR CIGNA DENTAL PPO PLAN BENEFITS Please refer to Appendix A for some commonly used services that are covered by the Cigna Dental PPO Plan. Contact Cigna’s Member Services at 1-800-516-9104, to find out how services not listed here are covered. What to Do in an Emergency The plan does not cover services provided in a hospital room, surgi-center or urgent care facility. You are covered for procedures provided in a dental office by a licensed dentist, provided they are covered under the plan. If you have an urgent dental condition, you should seek treatment at the nearest dentist’s office, regardless of whether the dentist participates in the plan’s dental network. An urgent dental condition is when dental services are required immediately to alleviate pain or treat the sudden onset of an acute dental condition, which if not treated will likely result in a more serious dental or medical condition. You do not need prior approval. However, the plan will only pay for covered services (at the negotiated rate for either a network or a non-network provider). Pre-Treatment Plan If you need specialist care, orthodontic care or any other dental care that is expected to cost $200 or more, we recommend that you ask your dentist to prepare a pre-treatment plan. To file a pre-treatment plan, your dentist should complete a claim form he/she should omit the dates of service and identify it as a “pre-estimate” versus a claim for actual services. Once the form is complete, your dentist should return it to the address shown on the form before your care begins. You and your dentist will receive an explanation of benefits that details the benefits payable under the plan. The pretreatment review of benefits is valid for 12 months, unless your benefits or eligibility change. What Is Covered The Cigna Dental PPO Plan covers certain dental services and supplies, which meet the plan’s definition of covered dental services. Please refer to Appendix A. Preventive Care
Oral exams and cleanings, three times every calendar year
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Bitewing X-rays, two times every calendar year
Full-mouth X-rays, once every three calendar years
Panoramic X-rays, once every three calendar years
Fluoride treatments for dependents up to age 19, once every calendar year
Sealants for permanent molars for children up to age 14, once every three calendar years
Emergency dental treatment
Space maintainers, fixed unilateral limited to non-orthodontic treatment
Periodontal cleaning (only after active periodontal treatment).
Restorative Care
Amalgam and composite/resin fillings
Root canal therapy, including X-rays, tests, exams and follow-up care related to the root canal
Osseous surgery
Periodontal scaling and root planing entire mount
Denture adjustments complete denture
Bridge recementation
Simple extractions
Surgical removal of erupted teeth
Removal of impacted teeth, soft tissue, partially bony, complete bony
Local anesthesia, analgesic and routine postoperative care for extractions and oral surgery
General anesthesia, if clinically necessary
Sedation, if clinically necessary.
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Major Care
Crowns/abutment crowns
Dentures
Bridges porcelain fused or resin with high noble metal
Abutment Crowns resin with high noble metal, porcelain resin with high noble metal or full cast gold.
Surgical implants
Prosthesis over Implant
Orthodontia
Orthodontic work-up, including X-rays, diagnostic casts and treatment and retention appliances
Active treatment
Fixed or removable appliances (for tooth guidance to control harmful habits) only one appliance per person.
What Is Not Covered The plan does not cover certain services, some of which are listed below. Please contact Cigna’s Member Services at 1-800-516-9104 to confirm whether or not your service will be covered.
Services performed for cosmetic reasons
Replacement of lost or stolen appliances
Bridge, crown or denture replacement within five years of when the appliance was installed unless: The replacement is made necessary by the placement of an original opposing full
denture or the necessary extraction of natural teeth The bridge, crown or denture, while in the mouth, was damaged beyond repair as
the result of an injury received while a person is insured for dental benefits
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Any replacement of a bridge, crown or denture which is or can be made usable according to common dental standards
Procedures, appliances or restorations (except full dentures) whose main purpose is to: Change vertical dimension Diagnose or treat TMJ Stabilize periodontally involved teeth Restore occlusion
Porcelain or acrylic veneers of crowns or pontics on or replacing the upper and lower first, second and third molars
Bite registrations, precision or semiprecision attachments or splinting
Instruction on plaque control, oral hygiene or diet
Dental services that do not meet common dental standards
Services that are deemed to be medical services
Services and supplies received from a hospital
Services for which benefits are not paid for by the Cigna Dental PPO Plan.
Prescription Drugs (If you are enrolled in a Visa-sponsored dental plan and your dentist prescribes drugs, you will need to have your dentist contact your physician for approval of the expense. Prescription drugs are not covered under the dental plans; only the medical plans provide reimbursement for prescription drugs. If your physician does not approve your dentist's prescription, no prescription drug benefits will be payable.)
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CIRCUMSTANCES THAT MAY RESULT IN DENIAL, LOSS OR FORFEITURE OF BENEFITS No dental payments will be made for the following
Injuries that arise out of or in the course of any employment for wage or profit
Sicknesses that are covered under any workers’ compensation or similar law
Military-service-connected conditions which resulted in charges being incurred from a hospital owned or operated by or which provides care or performs services for, the United States government
Expenses that are incurred unlawfully
Charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received
charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law
Charges which would not have been made if the person had no insurance
Expenses that are greater than the contracted fee or the maximum reimbursable charge
Cigna Dental HMO Plan and Cigna Dental PPO Plan
Unnecessary care, treatment or surgery
Expenses that are paid for through a public program other than Medicaid
Experimental procedures or treatment methods not approved by the American
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Dental Association or the appropriate dental specialty society
Benefits that are payable under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law.
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ADDITIONAL RULES THAT APPLY TO THESE PLANS The following rules apply to your dental plans. Coordination of Benefits In situations where you have other coverage that pays as a primary plan, the Cigna Dental PPO plan has a provision to ensure that payments from all of your group dental plans do not exceed the amount the Cigna Dental PPO plan would pay if it were your only coverage. The Cigna Dental HMO plan has a provision to ensure that the payments from all of your group dental plans do not exceed 100% of the amount the Dental HMO Plan would pay if it were your only coverage. The rules described here apply to the Cigna Dental HMO plan and the Cigna Dental PPO plan. The following rules do not apply to any private, personal insurance you may have. Non-Duplication of Benefits – Cigna Dental PPO Plan If you and your eligible dependents are covered under more than one group plan, the primary plan (the one responsible for paying benefits first) needs to be determined. If the Cigna Dental PPO plan is paying secondary, your Cigna Dental PPO plan coverage will ensure that, in total, you receive benefits up to what you would have received with Cigna A as your only source of coverage (but not in excess of that amount), based on the primary plan’s covered benefits. A summary of coordination rules (e.g., how Cigna coordinates coverage with another group plan to ensure non-duplication of benefits) is provided below. If you have questions, contact Cigna’s Member Services at 1-800-5169104 for help. Example: Assume your spouse has a clinically necessary procedure with a maximum reimbursable charge (MRC) of $100. If your spouse’s plan (which we will assume is primary) pays 70% for that procedure, your spouse will receive a $70 benefit (70% of $100). Also assume that your Cigna Dental PPO plan option (which we will assume is your spouse’s secondary coverage) would pay 80% for this clinically necessary procedure. In this case, your spouse normally would receive an $80 benefit (80% of $100) from the Cigna Dental PPO plan option. Because your spouse already received $70 from his/her primary plan, he/she would receive the balance ($10) from the Cigna Dental PPO plan.
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Standard Coordination of Benefits – Cigna DHMO Plan If you and your eligible dependents are covered under more than one group plan, the primary plan (the one responsible for paying benefits first) needs to be determined. If the Cigna DHMO Plan is paying secondary, your Cigna DHMO Plan coverage will ensure that, in total, you do not receive benefits in excess of 100% of what you would have received with Cigna as your only source of coverage, based on the primary plan’s covered benefits. A summary of coordination rules (e.g., how Cigna coordinates coverage with another group plan to ensure standard coordination of benefits) is provided below. If you have questions, contact Cigna’s Member Services at 1-800-5169104 for help. Example: Assume your spouse has a clinically necessary procedure with a maximum reimbursable charge of $100. If your spouse’s plan (which we will assume is primary) pays 70% for that procedure, your spouse will receive a $70 benefit (70% of $100). Also assume that your Cigna DHMO Plan option (which we will assume is your spouse’s secondary coverage) would pay 80% for this clinically necessary procedure. In this case, your spouse normally would receive an $80 benefit (80% of $100) from the Cigna DHMO Plan option. Because your spouse already received $70 from his/her primary plan, he/she would receive the balance ($30) from the Cigna DHMO Plan for a total benefit of 100% ($70 + $30 = $100). Determining Primary Coverage To determine which dental plan pays first as the primary plan, here are some general guidelines:
As an active employee, the Cigna Dental DHMO Plan or the Cigna Dental PPO Plan will consider claims for your dental expenses first. If you are retired, the Cigna Dental DHMO Plan or the Cigna Dental PPO Plan will pay second.
If your covered dependent has a claim, the plan covering your dependent as an employee will pay first. If your claim is for a covered dependent child, the plan covering the parent who has the earlier birthday in a calendar year will pay first. In the event of divorce or legal separation, and in the absence of a qualified medical child support order, the plan covering the parent with court-decreed financial responsibility will pay first. If there is no court decree, the plan of the parent who has
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Cigna Dental HMO Plan and Cigna Dental PPO Plan
custody of the covered dependent child will pay first. Please refer to the SPD for the Visa Retiree Health Plan for more information regarding a qualified medical child support order.
If you are a retiree employed elsewhere and covered under another employer’s plan, that plan will be responsible for paying claims first for you and your dependents.
If your other dental plan does not have a coordination of benefits provision, that plan will pay first for you and your covered dependents.
If payment responsibilities are still unresolved, the plan that has covered the claimant the longest pays first.
After it is determined which plan pays benefits first, you will need to submit your initial claim to that plan. After the first plan pays your benefits (up to the limits of its coverage), you can then submit the claim to the other plan (the secondary plan) to consider your claim for any unpaid amounts. You will need to include a copy of the written explanation of benefits (EOB) from your primary plan. HOW TO REACH THE PLAN Here is how you can reach your dental plan provider: Plan
Phone Number
Web Site Address
Cigna Dental PPO Plan
1-800-516-9104
http://www.cigna.com
Cigna Dental DHMO Plan
1-800-516-9104
http://www.cigna.com
Visa Benefits
[email protected]
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CLAIM PROCEDURES FOR CIGNA DENTAL PPO PLAN Filing a Claim If you are enrolled in the Cigna Dental DHMO Plan, you do not have to file a claim when you use a Network General Dentist. If you are enrolled in the Cigna Dental PPO Plan, you do not need to file a claim if you use a network dentist. To receive benefits for care obtained from a dentist who is not part of the network, you should mail your completed claim form and original itemized bills to the address below. Please refer to http://benefitsource.visa.com to obtain the appropriate claim form. Send your claims to… Cigna Dental - Sherman P.O. Box 188037 Chattanooga, TN 37422-8037 Time Frame for Initial Claim Determination For urgent care claims (see definition on page 18) and pre-service claims (claims that require approval of the benefit before receiving care), the plan’s claims administrator will notify you whether your claim for benefits under the plan is approved or not within the following time frames:
As soon as possible, taking into account the exigencies, but not later than 72 hours after receipt of a claim initiated for urgent care (a decision can be provided to you orally, as long as a written or electronic notification is provided to you within three days after the oral notification)
Within a reasonable period of time appropriate to the circumstances, but not later than 15 days after receipt of a pre-service claim.
For post-service claims (claims that are submitted for payment after receiving care), the claim administrator will notify you in writing or electronically of an adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of a claim. An adverse benefit determination is any denial, reduction or termination of a benefit, or a failure to provide or make a payment, in whole or in part, for a benefit.
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For urgent care claims, if you fail to provide the claim administrator with sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan, the claim administrator will notify you within 24 hours of receiving your claim of the specific information needed to complete the claim. You then have 48 hours to provide the information needed to process the claim. You will be notified of a determination no later than 48 hours after the earlier of:
The claim administrator’s receipt of the requested information
The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time.
For pre- and post-service claims, a 15-day extension may be allowed to make a determination, provided that the claim administrator determines that the extension is necessary due to matters beyond its control. If such an extension is necessary, the claim administrator will notify you before the end of the first 15- or 30-day period of the reason(s) requiring the extension and the date it expects to provide a decision on your claim. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will also specifically describe the required information. You then have 45 days to provide the information needed to process your claim. If an extension is necessary for pre- and post-service claims due to your failure to submit necessary information, the period for making a benefit determination is stopped from the date the claim administrator sends you an extension notification until the date you respond to the request for additional information. In addition, if you or your authorized representative fail to follow the plan’s procedures for filing a pre-service claim, you or your authorized representative will be notified of the failure and the proper procedures to be followed in filing a claim for such benefits. This notification will be provided within five days (24 hours in the case of a failure to file a pre-service claim involving urgent care) following the failure. Notification may be oral, unless you or your authorized representative requests written notification. This paragraph only applies to a failure that:
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Is a communication by you or your authorized representative that is received by a person or organizational unit customarily responsible for handling benefit matters and
Is a communication that names you, a specific clinical condition or symptom, and a specific treatment, service or product for which approval is requested. Urgent Care Claims Urgent care claims are those which, unless the special urgent care deadlines for response to a claim are followed, either:
Could seriously jeopardize the patient’s life, health or ability to regain maximum function or
In the opinion of a physician with knowledge of the patient’s clinical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested in the claim for benefits.
An individual acting on behalf of the plan, applying the judgment of a prudent layperson who has an average knowledge of health and medicine, can determine whether the urgent care definition has been satisfied. However, if a physician with knowledge of the patient’s clinical condition determines that the claim involves urgent care, it must be considered an urgent care claim.
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Concurrent Care Claims Request to Extend Treatment If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent care claim as defined earlier, your request will be decided and you will be notified of the decision within 24 hours of the claim administrator’s receipt of the claim, provided your request is made at least 24 hours prior to the end of the approved treatment. If the request is not made within 24 hours before the end of the approved treatment, the request will be treated as an urgent care claim and decided according to the urgent care claim time frames described earlier. If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend treatment is a non-urgent circumstance, your request will be considered a new claim and decided according to pre-service or post-service time frames described above, whichever applies. Note: Any reduction or termination of a course of treatment will not be considered an adverse benefit determination if the reduction or termination of the treatment is the result of a plan amendment or plan termination. If You Receive an Adverse Benefit Determination The claim administrator will provide you with a notification of any adverse benefit determination, which will set forth:
The specific reason(s) for the adverse benefit determination
References to the specific plan provisions on which the benefit determination is based
A description of any additional material or information needed to process the claim and an explanation of why that material or information is necessary
A description of the plan’s appeal procedures and the time limits applicable to those procedures, including a statement of your right to bring a civil action under ERISA after an appeal of an adverse benefit determination
Cigna Dental HMO Plan and Cigna Dental PPO Plan
22
Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination or a statement that a copy of this information will be provided free of charge to you upon request
If the adverse benefit determination was based on a clinical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your clinical circumstances, or a statement that such explanation will be provided free of charge upon request
If the adverse benefit determination concerns a claim involving urgent care, a description of the expedited review process applicable to the claim.
Procedures for Appealing an Adverse Benefit Determination If you receive an adverse benefit determination, you may ask for a review. You, or your authorized representative, have 180 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination. You have the right to:
Submit written comments, documents, records and other information relating to the claim for benefits
Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits.
A review that takes into account all comments, documents, records and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination
A review that does not defer to the initial adverse benefit determination and that is conducted neither by the individual who made the adverse determination, nor that person’s subordinate
A review in which the named fiduciary consults with a health care professional who has appropriate training and experience in the field of dentistry involved in the judgment, and who was neither consulted in connection with the initial adverse
Cigna Dental HMO Plan and Cigna Dental PPO Plan
23
benefit determination, nor the subordinate of any such individual. This applies only if the appeal involves an adverse benefit determination based in whole or in part on a judgment (including whether a particular treatment, drug or other item is experimental)
The identification of dental or vocational experts whose advice was obtained in connection with the adverse benefit determination, regardless of whether the advice was relied upon in making the decision
In the case of a claim for urgent care, an expedited review process in which: You may submit a request (orally or in writing) for an expedited appeal of an
adverse benefit determination All necessary information, including the plan’s benefit determination on review,
will be transmitted between the plan and you by telephone, facsimile or other available similarly prompt method. A decision regarding your appeal will be reached:
As soon as possible, taking into account the exigencies, but not later than 72 hours after receipt of your request for review of an urgent care claim
Within a reasonable period of time appropriate to the circumstances, but not later than 30 days after receipt of your request for review of a pre-service claim
Within 60 days after receipt of your request for review of a post-service claim.
The claim administrator’s notice of an adverse benefit determination on appeal will be provided in writing or electronically and will contain all of the following information:
The specific reason(s) for the adverse benefit determination
References to the specific plan provisions on which the benefit determination is based
A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records and other information relevant to your claim
Cigna Dental HMO Plan and Cigna Dental PPO Plan
24
A statement describing any voluntary appeal procedures offered by the plan and your right to obtain the information about such procedures, and a statement of your right to bring an action under ERISA
Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination; or a statement that a copy of this information will be provided free of charge to you upon request
If the adverse benefit determination was based on a clinical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your clinical circumstances or a statement that such explanation will be provided free of charge upon request.
What To Do If There Is A Problem with your Cigna Dental DHMO Plan Most problems can be resolved between you and your dentist. However, we want you to be completely satisfied with the Dental Plan. That is why we have established a process for addressing your concerns and complaints. The complaint procedure is voluntary and will be used only upon your request. A. Your Rights to File Grievances With Cigna Dental We want you to be completely satisfied with the care you receive. That is why we have established an internal grievance process for addressing your concerns and resolving your problems. Grievances include both complaints and appeals. Complaints may include concerns about people, quality of service, quality of care, benefit interpretations or eligibility. Appeals are requests to reverse a prior denial or modified decision about your care. You may contact us by telephone or in writing with a grievance. B. How to File a Grievance To contact us by phone, call us toll-free at 1-800- Cigna 24 or the toll-free telephone number on your Cigna identification card. The hearing impaired may call the state TTY toll-free service listed in their local telephone directory.
Cigna Dental HMO Plan and Cigna Dental PPO Plan
25
Send written grievances to: Cigna Dental Health P.O. Box 188047 Chattanooga, TN 37422-8047 We will provide you with a grievance form upon request, but you are not required to use the form in order to make a written grievance. You may also submit a grievance online through the following Cigna website: http://www.cigna.com/health/consumer/medical/state/ca.html#dental. If the Member is a minor, is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative, or other legal representative acting on behalf of the Member, as appropriate, may submit a grievance to Cigna Dental or the California Department of Managed Health Care (DMHC or “Department”), as the agent of the Member. Also, a participating provider may join with or assist you or your agent in submitting a grievance to Cigna Dental or the DMHC. 1. Complaints If you are concerned about the quality of service or care you have received, a benefit interpretation, or have an eligibility issue, you should contact us to file a verbal or written complaint. If you contact us by telephone to file a complaint, we will attempt to document and/or resolve your complaint over the telephone. If we receive your complaint in writing, we will send you a letter confirming that we received the complaint within 5 calendar days of receiving your notice. This notification will tell you whom to contact should you have questions or would like to submit additional information about your complaint. We will investigate your complaint and will notify you of the outcome within 30 calendar days. 2. Appeals If your grievance does not involve a complaint about the quality of service or care, a benefit interpretation or an eligibility issue, but instead involves dissatisfaction with the outcome of a decision that was made about your care and
Cigna Dental HMO Plan and Cigna Dental PPO Plan
26
you want to request Cigna Dental to reverse the previous decision, you should contact us within one year of receiving the denial notice to file a verbal or written appeal. Be sure to share any new information that may help justify a reversal of the original decision. Within 5 calendar days from when we receive your appeal, we will confirm with you, in writing, that we received it. We will tell you whom to contact at Cigna Dental should you have questions or would like to submit additional information about your appeal. We will make sure your appeal is handled by someone who has authority to take action and who was not involved in the original decision. We will investigate your appeal and notify you of our decision, within 30 calendar days. You may request that the appeal process be expedited, if there is an imminent and serious threat to your health, including severe pain, potential loss of life, limb or major bodily function. A Dental Director for Cigna Dental, in consultation with your treating dentist, will decide if an expedited appeal is necessary. When an appeal is expedited, Cigna Dental will respond orally and in writing with a decision within 72 hours. C. You Have Additional Rights Under State Law Cigna Dental is regulated by the California Department of Managed Health Care (DMHC or the “Department”). If you are dissatisfied with the resolution of your complaint or appeal, the law states that you have the right to submit the grievance to the department for review as follows: The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800- Cigna 24 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity
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of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. You may file a grievance with the DMHC if Cigna Dental has not completed the complaint or appeal process described above within 30 days of receiving your grievance. You may immediately file an appeal with Cigna Dental and/or the DMHC in a case involving an imminent and serious threat to the health, including, but not limited to, severe pain, the potential loss of life, limb, or major bodily function, or in any other case where the DMHC determines that an earlier review is warranted. D. Voluntary Mediation If you have received an appeal decision from Cigna Dental with which you are not satisfied, you may also request voluntary mediation with us before exercising the right to submit a grievance to the DMHC. In order for mediation to take place, you and Cigna Dental each have to voluntarily agree to the mediation. Cigna Dental will consider each request for mediation on a case by case basis. Each side will equally share the expenses of the mediation. To initiate mediation, please submit a written request to the Cigna Dental address listed above. If you request voluntary mediation, you may elect to submit your grievance directly to the DMHC after participating in the voluntary mediation process for at least 30 days. For more specific information regarding these grievance procedures, please contact our Member Services Department.
28
Cigna Dental PPO Plan
APPENDIX A – CIGNA DENTAL PPO BENEFIT SUMMARY In-Network
Out-of-Network
$2,000
$2,000
$25 per person $50 per family
$25 per person $50 per family
Plan Pays
Plan Pays
Class I – Preventive and diagnostic services Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Sealants Space Maintainers Emergency Care to Relieve Pain
100%
100%
Class II – Basic restorative services Fillings Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Adjustments and Repairs Oral Surgery Repairs to Crowns and Inlays Surgical Extractions of Impacted Teeth Anesthetics Simple extractions
90% after deductible
80% after deductible
Class III – Major restorative services Crowns Inlays/Onlays Prosthesis Over Implant Dentures Bridges
60% after deductible
50% after deductible
Class IV – Orthodontia (covered for employees and all dependents)
50% after deductible
50% after deductible
$2,000
$1,000
Calendar Year Maximum (Class I, II and III expenses) Annual Deductible
Lifetime maximum Missing Tooth Limitation
None
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Cigna Dental PPO Plan
Pretreatment review is suggested when dental work in excess of $200 is proposed. All plan deductibles and maximums (dollar and occurrence) cross-accumulate between In-Network and Outof-Network unless otherwise noted. Standard Exclusions & Limitations:
Cigna Dental PPO Exclusions and Limitations Procedure Exams Prophylaxis (cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine ) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs – Bridges Repairs – Dentures Sealants Space Maintainers Implants
Prosthesis Over Implant
Alternate Benefit
Exclusions & Limitations Three per Calendar year Three per Calendar year 1 per calendar year for people under 19 Various limits per calendar year depending on specific test Bitewings: 2 per calendar year Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years Payable only when in conjunction with Ortho workup and extensive Perio treatment Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth for a person less than 14. One treatment per tooth every three years Limited to non-Orthodontic treatment Benefit includes the surgical placement of the implant body or framework of any type; any device, index, or surgical template guide used for implant surgery; prefabricated or custom implant abutments; or removal of an existing implant. Implant removal is covered only if the implant is not serviceable and cannot be repaired. 1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges. When more than one covered Dental Service could provide suitable treatment based on common dental standards, CG will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.
Cigna Dental PPO Plan
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Benefit Exclusions: Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation
unless: (a) such replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or (b) the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received Charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers' compensation or similar law Charges in excess of the maximum reimbursable charge To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured
Cigna Dental PPO Plan
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motorist insurance law. Connecticut General Life Insurance Company will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer. This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company.
32
CignaDental HMO Plan
APPENDIX B – CIGNA DENTAL DHMO PATIENT CHARGE SCHEDULE
Cigna Dental Care® (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
Important Highlights ■ This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. ■ This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist, Orthodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Member Services at 1.800. Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.
■ Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient’s responsibility at the dentist’s usual fees. ■ The administration of IV sedation, general anesthesia, and/or Nitrous Oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. ■ Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. ■ This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. ■ Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.
■ All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.
■ The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.
33
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Diagnostic/Preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic Oral Evaluations (D0120), Comprehensive Oral Evaluations (D0150), Comprehensive Periodontal Evaluations (D0180), and Oral Evaluations for Patients Under 3 Years of Age (D0145). D9310
Consultation (Diagnostic Service Provided by Dentist or Physician Other than Requesting Dentist or Physician)
$0.00
D9430
Office Visit for Observation – No Other Services Performed
$0.00
D9450
Case Presentation – Detailed and Extensive Treatment Planning
$0.00
D0120
Periodic Oral Evaluation – Established Patient
$0.00
D0140
Limited Oral Evaluation – Problem Focused
$0.00
D0145
Oral Evaluation for a Patient Under 3 Years of Age and Counseling with Primary Caregiver
$0.00
D0150
Comprehensive Oral Evaluation – New or Established Patient
$0.00
D0170
Re-evaluation – Problem Focused (Not Postoperative Visit)
$0.00
D0210
X-Rays Intraoral – Complete Series (Including Bitewings) (Limit 1 Every 3 Years)
$0.00
D0220
X-Rays Intraoral – Periapical – First Film
$0.00
D0230
X-Rays Intraoral – Periapical – Each Additional Film
$0.00
D0240
X-Rays Intraoral – Occlusal Film
$0.00
D0270
X-Rays (Bitewing) – Single Film
$0.00
D0272
X-Rays (Bitewings) – 2 Films
$0.00
D0273
X-Rays (Bitewings) – 3 Films
$0.00
D0274
X-Rays (Bitewings) – 4 Films
$0.00
D0277
X-Rays (Bitewings, Vertical) – 7 to 8 Films
$0.00
D0330
X-Rays (Panoramic Film) – (Limit 1 Every 3 Years)
$0.00
D0431
Oral Cancer Screening Using a Special Light Source
$50.00
D0460
Pulp Vitality Tests
$14.00
34
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D0470
Diagnostic Casts
$0.00
D0472
Pathology Report – Gross Examination of Lesion (Only When Tooth Related)
$0.00
D0473
Pathology Report – Microscopic Examination of Lesion (Only When Tooth Related)
$0.00
D0474
Pathology Report – Microscopic Examination of Lesion and Area (Only When Tooth Related)
$0.00
D1110
Cleaning (Prophylaxis) – Adult (Limit 2 per Calendar Year) $0.00 Additional Cleaning (Prophylaxis) – In Addition to the 2 Cleanings (Prophylaxes) Allowed per Calendar Year
$0.00
Cleaning (Prophylaxis) – Child (Limit 2 per Calendar Year) $0.00 Additional Cleaning (Prophylaxis) – In Addition to the 2 Cleanings (Prophylaxes) Allowed per Calendar Year
$0.00
D1203
Topical Fluoride Application – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.
$0.00
D1206
Topical Fluoride Varnish – Therapeutic Application for Moderate to High Caries Risk Patients – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.
$0.00
D1330
Oral Hygiene Instructions
$0.00
D1351
Sealant – Per Tooth
$0.00
D1510
Space Maintainer – Fixed – Unilateral
$0.00
D1515
Space Maintainer – Fixed – Bilateral
$0.00
D1555
Removal of Fixed Space Maintainer
$0.00
D1120
$45.00
$30.00
Restorative – Fillings D2140
Amalgam – 1 Surface, Primary or Permanent
$0.00
D2150
Amalgam – 2 Surfaces, Primary or Permanent
$0.00
D2160
Amalgam – 3 Surfaces, Primary or Permanent
$0.00
35
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D2161
Amalgam – 4 or More Surfaces, Primary or Permanent
$0.00
D2330
Resin-Based Composite – 1 Surface, Anterior
$0.00
D2331
Resin-Based Composite – 2 Surfaces, Anterior
$0.00
D2332
Resin-Based Composite – 3 Surfaces, Anterior
$0.00
D2335
Resin-Based Composite – 4 or More Surfaces or Involving Incisal Angle, Anterior
$88.00
D2390
Resin-Based Composite Crown, Anterior
$59.00
D2391
Resin-Based Composite – 1 Surface, Posterior
$47.00
D2392
Resin-Based Composite – 2 Surfaces, Posterior
$59.00
D2393
Resin-Based Composite – 3 Surfaces, Posterior
$82.00
D2394
Resin-Based Composite – 4 or More Surfaces, Posterior
$115.00
Crown and Bridge – All charges for crown and bridge are per unit (each replacement or supporting tooth equals 1 unit) – Replacement limit 1 every 5 years. D2510
Inlay – Metallic – 1 Surface
$350.00
D2520
Inlay – Metallic – 2 Surfaces
$350.00
D2530
Inlay – Metallic – 3 or More Surfaces
$350.00
D2542
Onlay – Metallic – 2 Surfaces
$400.00
D2543
Onlay – Metallic – 3 Surfaces
$400.00
D2544
Onlay – Metallic – 4 or More Surfaces
$400.00
D2740
Crown – Porcelain/Ceramic Substrate
$415.00
D2750
Crown – Porcelain Fused to High Noble Metal
$380.00
D2751
Crown – Porcelain Fused to Predominantly Base Metal
$335.00
D2752
Crown – Porcelain Fused to Noble Metal
$355.00
D2780
Crown – 3/4 Cast High Noble Metal
$390.00
D2781
Crown – 3/4 Cast Predominantly Base Metal
$345.00
D2782
Crown – 3/4 Cast Noble Metal
$365.00
D2790
Crown – Full Cast High Noble Metal
$390.00
D2791
Crown – Full Cast Predominantly Base Metal
$345.00
D2792
Crown – Full Cast Noble Metal
$365.00
D2794
Crown – Titanium
$390.00
D2910
Recement Inlay – Onlay or Veneer
$12.00
36
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D2915
Recement Cast or Prefabricated Post and Core
$12.00
D2920
Recement Crown
$12.00
D2930
Prefabricated Stainless Steel Crown – Primary Tooth
$12.00
D2931
Prefabricated Stainless Steel Crown – Permanent Tooth
$12.00
D2932
Prefabricated Resin Crown
$110.00
D2933
Prefabricated Stainless Steel Crown with Resin Window
$115.00
D2934
Prefabricated Esthetic Coated Stainless Steel Crown – Primary Tooth
$115.00
D2940
Sedative Filling
$13.00
D2950
Core Buildup – Including Any Pins
$92.00
D2951
Pin Retention – Per Tooth – In Addition to Restoration
$19.00
D2952
Cast Post and Core – In Addition to Crown
$135.00
D2954
Prefabricated Post and Core – In Addition to Crown
$115.00
D2960
Labial Veneer (Resin Laminate) – Chairside
$110.00
D6210
Pontic – Cast High Noble Metal
$380.00
D6211
Pontic – Cast Predominantly Base Metal
$345.00
D6212
Pontic – Cast Noble Metal
$365.00
D6214
Pontic – Titanium
$390.00
D6240
Pontic – Porcelain Fused to High Noble Metal
$380.00
D6241
Pontic – Porcelain Fused to Predominantly Base Metal
$345.00
D6242
Pontic – Porcelain Fused to Noble Metal
$365.00
D6245
Pontic – Porcelain/Ceramic
$380.00
D6602
Inlay – Cast High Noble Metal, 2 Surfaces
$390.00
D6603
Inlay – Cast High Noble Metal, 3 or More Surfaces $390.00
D6604
Inlay – Cast Predominantly Base Metal, 2 Surfaces
$345.00
D6605
Inlay – Cast Predominantly Base Metal, 3 or More Surfaces
$335.00
D6606
Inlay – Cast Noble Metal, 2 Surfaces
$345.00
37
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D6607
Inlay – Cast Noble Metal, 3 or More Surfaces
$355.00
D6610
Onlay – Cast High Noble Metal, 2 Surfaces
$390.00
D6611
Onlay – Cast High Noble Metal, 3 or More Surfaces
$390.00
D6612
Onlay – Cast Predominantly Base Metal, 2 Surfaces
$335.00
D6613
Onlay – Cast Predominantly Base Metal, 3 or More Surfaces
$335.00
D6614
Onlay – Cast Noble Metal, 2 Surfaces
$355.00
D6615
Onlay – Cast Noble Metal, 3 or More Surfaces
$365.00
D6624
Inlay – Titanium
$380.00
D6634
Onlay – Titanium
$380.00
D6740
Crown – Porcelain/Ceramic
$425.00
D6750
Crown – Porcelain Fused to High Noble Metal
$390.00
D6751
Crown – Porcelain Fused to Predominantly Base Metal
$345.00
D6752
Crown – Porcelain Fused to Noble Metal
$365.00
D6780
Crown – 3/4 Cast High Noble Metal
$390.00
D6781
Crown – 3/4 Cast Predominantly Base Metal
$345.00
D6782
Crown – 3/4 Cast Noble Metal
$365.00
D6790
Crown – Full Cast High Noble Metal
$390.00
D6791
Crown – Full Cast Predominantly Base Metal
$345.00
D6792
Crown – Full Cast Noble Metal
$365.00
D6794
Crown – Titanium
$390.00
Complex Rehabilitation – ADDITIONAL CHARGE PER UNIT FOR MULTIPLE CROWN UNITS/COMPLEX REHABILITATION (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)
$135.00
Recement Fixed Partial Denture
$12.00
D6930
38
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Implant Supported Prosthetics – All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit) – Replacement limit 1 every 5 years. All charges for an implant supported denture are limited to replacement of 1 every 5 years. D6053
Implant/Abutment Supported Removable Denture for Completely Edentulous Arch
$800.00
D6054
Implant/Abutment Supported Removable Denture for Partially Edentulous Arch
$875.00
D6058
Abutment Supported Porcelain/Ceramic Crown
$715.00
D6059
Abutment Supported Porcelain Fused to Metal Crown (High Noble Metal)
$680.00
D6060
Abutment Supported Porcelain Fused to Metal Crown (Predominantly Base Metal)
$635.00
D6061
Abutment Supported Porcelain Fused to Metal Crown (Noble Metal)
$655.00
D6062
Abutment Supported Cast Metal Crown (High Noble Metal)
$680.00
D6063
Abutment Supported Cast Metal Crown (Predominantly Base Metal)
$635.00
D6064
Abutment Supported Cast Metal Crown (Noble Metal)
$655.00
D6065
Implant Supported Porcelain/Ceramic Crown
$715.00
D6066
Implant Supported Porcelain Fused to Metal Crown (Titanium, Titanium Alloy, High Noble Metal)
$680.00
D6067
Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)
$680.00
D6068
Abutment Supported Retainer for Porcelain/Ceramic Fixed Partial Denture
$715.00
D6069
Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (High Noble Metal)
$680.00
D6070
Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (Predominantly Base Metal)
$635.00
D6071
Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (Noble Metal)
$655.00
D6072
Abutment Supported Retainer for Cast Metal Fixed Partial Denture (High Noble Metal)
$680.00
39
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D6073
Abutment Supported Retainer for Cast Metal Fixed Partial Denture (Predominantly Base Metal)
$635.00
D6074
Abutment Supported Retainer for Cast Metal Fixed Partial Denture (Noble Metal)
$655.00
D6075
Implant Supported Retainer for Ceramic Fixed Partial Denture
$715.00
D6076
Implant Supported Retainer for Porcelain Fused to $680.00 Metal Fixed Partial Denture (Titanium, Titanium Alloy, High Noble Metal)
D6077
Implant Supported Retainer for Cast Metal Fixed Partial Denture (Titanium, Titanium Alloy, High Noble Metal)
$680.00
D6078
Implant Supported Retainer for Cast Metal Fixed Partial Denture (Titanium, Titanium Alloy, High Noble Metal)
$800.00
D6079
Implant/Abutment Supported Fixed Denture for Partially Edentulous Arch
$875.00
D6092
Recement Implant/Abutment Supported Crown
$51.00
D6093
Recement Implant/Abutment Supported Fixed Partial Denture
$51.00
D6094
Abutment Supported Crown (Titanium)
$680.00
D6194
Abutment Supported Retainer Crown for Fixed Partial Denture (Titanium) Complex Rehabilitation on Implant Supported Prosthetic Procedures – ADDITIONAL CHARGE PER UNIT FOR MULTIPLE CROWN UNITS/COMPLEX REHABILITATION (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)
$680.00 $135.00
40
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Endodontics – Root Canal Treatment, Excluding Final Restorations D3110
Pulp Cap – Direct (Excluding Final Restoration)
$14.00
D3120
Pulp Cap – Indirect (Excluding Final Restoration)
$14.00
D3220
Pulpotomy – Removal of Pulp, Not Part of a Root Canal
$21.00
D3221
Pulpal Debridement (Not to be used when root canal is done on the same day)
$21.00
D3222
Partial Pulpotomy for Apexogenesis – Permanent Tooth with Incomplete Root Development
$21.00
D3310
Anterior Root Canal – Permanent Tooth (Excluding Final Restoration)
$12.00
D3320
Bicuspid Root Canal – Permanent Tooth (Excluding Final Restoration)
$31.00
D3330
Molar Root Canal – Permanent Tooth (Excluding Final Restoration)
$280.00
D3331
Treatment of Root Canal Obstruction – Nonsurgical Access
$14.00
D3332
Incomplete Endodontic Therapy – Inoperable or Fractured Tooth
$14.00
D3333
Internal Root Repair of Perforation Defects
$14.00
D3346
Retreatment of Previous Root Canal Therapy – Anterior
$14.00
D3347
Retreatment of Previous Root Canal Therapy – Bicuspid
$34.00
D3348
Retreatment of Previous Root Canal Therapy – Molar
$370.00
D3410
Apicoectomy/Periradicular Surgery – Anterior
$155.00
D3421
Apicoectomy/Periradicular Surgery – Bicuspid (First Root)
$185.00
D3425
Apicoectomy/Periradicular Surgery – Molar (First Root)
$220.00
D3426
Apicoectomy/Periradicular Surgery (Each Additional Root)
$58.00
D3430
Retrograde Filling per Root
$40.00
41
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Periodontics – Treatment of Supporting Tissues (Gum and Bone) of the Teeth. Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The Relevant Procedure Codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 Teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the Patient Charge Schedule. D0180
Comprehensive Periodontal Evaluation – New or Established Patient
$40.00
D4210
Gingivectomy or Gingivoplasty – 4 or More Teeth per Quadrant
$220.00
D4211
Gingivectomy or Gingivoplasty – 1 to 3 Teeth per Quadrant
$105.00
D4240
Gingival Flap (Including Root Planing) – 4 or More Teeth per Quadrant
$280.00
D4241
Gingival Flap (Including Root Planing) – 1 to 3 Teeth per Quadrant
$155.00
D4245
Apically Positioned Flap
$280.00
D4249
Clinical Crown Lengthening – Hard Tissue
$315.00
D4260
Osseous Surgery – 4 or More Teeth per Quadrant
$465.00
D4261
Osseous Surgery – 1 to 3 Teeth per Quadrant
$270.00
D4263
Bone Replacement Graft – First Site in Quadrant
$290.00
D4264
Bone Replacement Graft – Each Additional Site in Quadrant
$225.00
D4266
Guided Tissue Regeneration – Resorbable Barrier per Site
$380.00
D4267
Guided Tissue Regeneration – Nonresorbable Barrier per Site (Includes Membrane Removal)
$430.00
D4270
Pedicle Soft Tissue Graft Procedure
$380.00
D4271
Free Soft Tissue Graft Procedure (Including Donor Site Surgery)
$360.00
D4275
Soft Tissue Allograft
$380.00
D4341
Periodontal Scaling and Root Planing – 4 or More Teeth per Quadrant (Limit 4 Quadrants per Consecutive 12 Months)
$96.00
D4342
Periodontal Scaling and Root Planing – 1 to 3 Teeth – per Quadrant (Limit 4 Quadrants per Consecutive 12 Months)
$48.00
42
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D4355
Full Mouth Debridement to Allow Evaluation and Diagnosis (1 per Lifetime)
$86.00
D4381
Localized Delivery of Chemotherapeutic Agents per Tooth – By Report
$45.00
D4910
Periodontal Maintenance (Limited to 2 per Calendar Year) (Only Covered after Active Therapy)
$66.00
D9940
Occlusal Guard – By Report (Limit 1 per 24 Months)
$245.00
D9951
Occlusal Adjustment Limited
$53.00
D9952
Occlusal Adjustment Complete
$255.00
Prosthetics - Removable Tooth Replacement – Dentures. Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. D5110
Full Upper Denture
$500.00
D5120
Full Lower Denture
$500.00
D5130
Immediate Full Upper Denture
$550.00
D5140
Immediate Full Lower Denture
$550.00
D5211
Upper Partial Denture – Resin Base (Including Clasps, Rests and Teeth)
$370.00
D5212
Lower Partial Denture – Resin Base (Including Clasps, Rests and Teeth)
$370.00
D5213
Upper Partial Denture – Metal (Including Clasps, Rests and Teeth)
$575.00
D5214
Lower Partial Denture – Metal (Including Clasps, Rests and Teeth)
$575.00
D5225
Upper Partial Denture – Flexible (Including Clasps, Rests and Teeth)
$400.00
D5226
Lower Partial Denture – Flexible (Including Clasps, Rests and Teeth)
$400.00
D5410
Adjust Complete Denture – Upper
$39.00
D5411
Adjust Complete Denture – Lower
$39.00
D5421
Adjust Partial Denture – Upper
$39.00
D5422
Adjust Partial Denture – Lower
$39.00
43
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Repairs to Prosthetics D5510
Repair Broken Complete Denture Base
$65.00
D5520
Replace Missing or Broken Teeth – Complete Denture (Each Tooth)
$65.00
D5610
Repair Resin Denture Base
$65.00
D5630
Repair or Replace Broken Clasp
D5640
Replace Broken Teeth – Per Tooth
$85.00 $65.00
D5650
Add Tooth to Existing Partial Denture
$65.00
D5660
Add Clasp to Existing Partial Denture
$85.00
Denture Relining - Limit 1 Every 36 Months D5710
Rebase Complete Upper Denture
$200.00
D5711
Rebase Complete Lower Denture
$200.00
D5720
Rebase Upper Partial Denture
$200.00
D5721
Rebase Lower Partial Denture
$200.00
D5730
Reline Complete Upper Denture – Chairside
$14.00
D5731
Reline Complete Lower Denture – Chairside
$14.00
D5740
Reline Upper Partial Denture – Chairside
$14.00
D5741
Reline Lower Partial Denture – Chairside
$14.00
D5750
Reline Complete Upper Denture – Laboratory
$170.00
D5751
Reline Complete Lower Denture – Laboratory
$170.00
D5760
Reline Upper Partial Denture – Laboratory
$170.00
D5761
Reline Lower Partial Denture – Laboratory
$170.00
Interim Dentures - Limit 1 Every 5 Years D5810
Interim Complete Denture – Upper
$290.00
D5811
Interim Complete Denture – Lower
$290.00
D5820
Interim Partial Denture – Upper
$235.00
D5821
Interim Partial Denture – Lower
$235.00
44
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
Oral Surgery - Includes Routine Postoperative Treatment. Surgical Removal of Impacted Tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111
Extraction of Coronal Remnants – Deciduous Tooth
$12.00
D7140
Extraction, Erupted Tooth or Exposed Root – Elevation and/or Forceps Removal
$12.00
D7210
Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth
$21.00
D7220
Removal of Impacted Tooth – Soft Tissue
$21.00
D7230
Removal of Impacted Tooth – Partially Bony
$73.00
D7240
Removal of Impacted Tooth – Completely Bony
$120.00
D7241
Removal of Impacted Tooth – Completely Bony, Unusual Complications (Narrative Required)
$135.00
D7250
Surgical Removal of Residual Tooth Roots – Cutting Procedure
$21.00
D7260
Oroantral Fistula Closure
$135.00
D7251
Coronectomy - Intentional Partial Tooth Removal
$73.00
D7261
Primary Closure of a Sinus Perforation
$135.00
D7270
Tooth Stabilization of Accidentally Evulsed or Displaced Tooth
$13.00
D7280
Surgical Access of an Unerupted Tooth (Excluding Wisdom Teeth)
$14.00
D7283
Placement of Device to Facilitate Eruption of Impacted Tooth
$8.00
D7285
Biopsy of Oral Tissue – Hard (Bone, Tooth) (Tooth Related – Not allowed when in conjunction with another surgical procedure)
$91.00
D7286
Biopsy of Oral Tissue – Soft (All Others) (Tooth Related – Not allowed when in conjunction with another surgical procedure)
$78.00
D7287
Exfoliative Cytological Sample Collection
$78.00
D7288
Brush Biopsy – Transepithelial Sample Collection
$78.00
D7310
Alveoloplasty in Conjunction with Extractions – 4 or More Teeth or Tooth Spaces per Quadrant
$14.00
D7311
Alveoloplasty in Conjunction with Extractions – 1 to 3 Teeth or Tooth Spaces per Quadrant
$8.00
45
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D7320
Alveoloplasty Not in Conjunction with Extractions – 4 or More Teeth or Tooth Spaces per Quadrant
$14.00
D7321
Alveoloplasty Not in Conjunction with Extractions – 1 to 3 Teeth or Tooth Spaces per Quadrant
$8.00
D7450
Removal of Benign Odontogenic Cyst or Tumor – Up to 1.25 cm
$14.00
D7451
Removal of Benign Odontogenic Cyst or Tumor – Greater than 1.25 cm
$14.00
D7471
Removal of Lateral Exostosis – Maxilla or Mandible
$14.00
D7472
Removal of Torus Palatinus
$14.00
D7473
Removal of Torus Mandibularis
$14.00
D7485
Surgical Reduction of Osseous Tuberosity
$14.00
D7510
Incision and Drainage of Abscess – Intraoral Soft Tissue
$14.00
D7511
Incision and Drainage of Abscess – Intraoral Soft Tissue Complicated
$20.00
D7960
Frenulectomy (Frenectomy or Frenotomy) – Separate Procedure
$14.00
D7963
Frenuloplasty
$20.00
Orthodontics - Tooth Movement. Orthodontic Treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8050
Interceptive Orthodontic Treatment of the Primary Dentition – Banding
$480.00
D8060
Interceptive Orthodontic Treatment of the Transitional Dentition – Banding
$480.00
D8070
Comprehensive Orthodontic Treatment of the Transitional Dentition – Banding
$500.00
D8080
Comprehensive Orthodontic Treatment of the Adolescent Dentition – Banding
$515.00
46
CignaDental HMO Plan
Code
Procedure Description
Patient Charge
D8090
Comprehensive Orthodontic Treatment of the Adult Dentition – Banding
$515.00
D8660
Pre-Orthodontic Treatment Visit
$68.00
D8670
Periodic Orthodontic Treatment Visit – As Part of Contract Children – Up to 19th Birthday: 24-Month Treatment Fee Charge per Month for 24 Months Adults: 24-Month Treatment Fee Charge per Month for 24 Months
$2,184.00 $91.00 $2,904.00 $121.00
D8680
Orthodontic Retention – Removal of Appliances, Construction and Placement of Retainer(s)
$345.00
D8999
Unspecified Orthodontic Procedure – By Report (Orthodontic Treatment Plan and Records)
$195.00
General Anesthesia/IV Sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9220
General Anesthesia – First 30 Minutes
$190.00
D9221
General Anesthesia – Additional 15 Minutes
$84.00
D9241
IV Conscious Sedation – First 30 Minutes
$190.00
D9242
IV Conscious Sedation – Additional 15 Minutes
$73.00
Emergency Services D9110
Palliative (Emergency) Treatment of Dental Pain – Minor Procedure
$0.00
D9440
Office Visit – After Regularly Scheduled Hours
$68.00
Code
Procedure Description
Patient Charge
Miscellaneous Services – External Bleaching (D9972) is limited to the use of take-home bleaching trays. All other bleaching methods are not covered. D9972
External Bleaching per Arch
$175.00
This Patient Charge Schedule may contain CDT codes and/or portions of, or excerpts from the Nomenclature contained within the Current Dental Terminology, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication. After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll-free number listed on your ID card or plan materials. Multiple ways to locate a *DHMO Network General Dentist: ■ Online provider directory at www.cigna.com ■ Online provider directory on my Cigna.com ■ Call the number located on your ID card to: ■ Use the Dental Office Locator via Speech Recognition ■ Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any licensed dentist. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations. * The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features.
