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Georgia
Institute of
Technology Dental Members |
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Schedule of Benefits PPO Plan
| Waiting Period for Type I Services: |
None |
| Waiting Period for Type II Services: |
None |
| Waiting Period for Type III Services: |
12 months* |
| Waiting Period for Type IV Services: |
12 months* |
| Dependent Age: |
19 |
| Dependent Maximum Age: |
26 |
| Annual Deductible |
$50 per person, Max 3 per family, Waived for Type I |
| Maximum Annual Payment |
$1,500
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*Credit given for time served under previous plan.
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| Type I - Diagnostic & Preventive Services |
In
Network |
Out of
Network* |
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| Cleanings, exams, x-rays |
100% |
100% |
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| Type II - Basic Restorative Services |
In
Network |
Out of
Network* |
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| Fillings, non-surgical extractions, non-surgical periodontics |
80% |
80% |
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| Type III - Major Services |
In
Network |
Out of
Network* |
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| Crowns, bridges, dentures, root canals, surgical extractions, surgical
periodontics |
50% |
50%
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| Type IV �
Orthodontia |
In
Network |
Out of
Network |
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| For dependent children to age 19 only |
50% |
50% |
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| Orthodontic Annual Maximum: |
$500 |
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| Orthodontic Lifetime Maximum: |
$1,000 |
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Orthodontic care will be
provided when in the opinion of the Orthodontic Consultant a
satisfactory result can be achieved.
Cross bite in permanent teeth will only be treated when, in the opinion
of the Orthodontic Consultant, other conditions are present which would
indicate that orthodontic treatment is necessary. Plan benefits shall
cover 24 months of usual and customary Orthodontic Care. Treatment
beyond said 24 months will not be covered.
Note: When using an out-of-network provider,
benefits are payable based on the Participating Dentist's Fee Schedule.
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Dental PPO Overview Elite Preferred 705 with OrthoThe PPO plan offers a variety of benefits with set
reimbursement amounts. You pay the provider for services at the time of
your appointment. Claim payments are then made to you or your provider.
The plan features:
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Freedom to choose any dentist |
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Quick claims turnaround |
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National coverage
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Frequently Asked Questions
How can I reduce Out-Of-Pocket Expenses?
By using one of our PPO Providers you have the benefit of reduced
out-of-pocket expenses. You also get additional peace of mind knowing that
our providers go through an extensive credentialing process.
How does the plan work?
1. The PPO plan allows you to seek treatment from any licensed dentist.
2. Once services are performed, you or your dentist must file a claim form
in order to receive reimbursement.
3. Your claim will be paid based on your group's schedule of benefits.
Benefits will be payable after your deductible and coinsurance (if
applicable) are satisfied. Your plan also has an annual limit on benefits
available.
The dentist may agree to file your insurance claim for you. However, if
he/she does not, you may be required to pay the entire bill at the time
services are rendered and submit a claim to CompBenefits for reimbursement.
Where should I send my claims?
Claim forms can be obtained from your Group Benefits Administrator or
CompBenefits Member Services and should be sent to:
CompBenefits Claims
PO Box 14283
Lexington, KY 40512-4283
Your provider may also file your claims electronically.
What is a predetermination?
The purpose of submitting a predetermination is to help you understand how
your benefits will be paid for your proposed treatment plan.
When is a predetermination needed?
If a planned treatment is going to cost over $200, you should ask the
dentist to file for predetermination of benefits before services begin.
How can I get further questions answered?
You may contact CompBenefits with any questions or concerns at
1-800-342-5209, M-F 8 am � 6 pm EST.
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