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Elite Preferred 510 with Ortho Overview
The 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:
 | Freedom to choose any dentist |
| Quick claims turnaround |
| National coverage |
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?
- The PPO plan allows you to seek treatment from any licensed dentist.
- Once services are performed, you or your dentist must file a claim
form in order to receive reimbursement.
- 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 8236
Chicago, IL 60680-8236
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. Locate us on the web at
www.compbenefits.com.
Monthy rates for: City of West Palm Beach
Effective date: January 1, 2004
Employee:
Contact HR for rates information.
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| Type I - Diagnostic
& Preventive |
Reimbursements |
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Oral Exam
Prophylaxis
Topical Fluoride
X-Rays
Sealants
Space Maintainers
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In
Network
100% |
Out of
Network*
100% |
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| Type II Basic Services |
Reimbursements |
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Simple Restorative
Periodontics
Emergency Palliative Treatment
Tooth Extraction
Endodontics
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In
Network
100% |
Out of
Network*
100% |
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| Type III - Major Services |
Reimbursements |
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(12 month waiting period)Major Restorative
Bridge, Denture Repair
Prosthetics
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In
Network
100% |
Out of
Network*
100% |
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| Type IV - Orthodontics |
Reimbursements |
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(12 month waiting period)
Dependent children 18 years of age or younger
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In
Network
100% |
Out of
Network*
100% |
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| MAXIMUM BENEFITS |
In
Network |
Out of
Network |
Lifetime
Type I, II, III
Type IV |
Unlimited
$4,000 |
Unlimited
$4,000 |
Calendar Year
Type I, II, III
Type IV |
$10,000
$2,000 |
$10,000
$2,000 |
Deductible $150 per
family maximum
Type I
Type II, III, IV |
Waived
Waived |
Waived
Waived |
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Exclusions
and Limitations |
*Coverage based on usual, customary and reasonable
fees.
Time served on the employer's immediately preceding group dental plan
may be credited towards this plan's waiting periods, subject to
Underwriting approval.
Certain exclusions and limitations apply. |
This schedule shows only a few of the covered procedures.
Please see your Benefit Administrator for a complete schedule. This schedule
is intended for comparison purposes only. The benefits for each plan will be
determined by the contract.
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