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Elite 510 with Ortho Schedule of Benefits
Because we specialize in dental, we can bring you benefits and service that
other companies can't match!
 | QUICK CLAIMS TURNAROUND
CompBenefits' state of the art claims center provides fast reimbursement
of your claims.
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 | ACCESS TO INFORMATION
Our toll-free customer service number at 1-(800)-342-5209 has Member
Services Representatives who can provide the answers you need quickly
and thoroughly.
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 | TOTAL FREEDOM OF CHOICE
The plan provides you with total freedom of choice by allowing
you to use any licensed dentist for treatment. The plan reimburses a
percentage of eligible expenses based on the plan you have chosen.
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Any way you add it up, CompBenefits
really is the benefits company of choice!
SUMMARY OF BENEFITS
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MAXIMUM BENEFITS
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Insured Individual and Dependents |
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In-Network
Reimbursements |
Out-of-Network
Reimbursements |
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Lifetime |
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Type I, II, III |
Unlimited |
Unlimited |
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Type IV |
$4,000 |
$4,000 |
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Calendar Year |
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Type I, II, III |
$10,000 |
$10,000 |
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Type IV |
$2,000 |
$2,000 |
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Deductible*** |
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Type I |
None |
None |
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Type II, III, IV |
None |
None |
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This brochure contains a brief description of the plan. A
complete description of the coverage, including limitations on certain
procedures, is found in the Schedule of Benefits and Certificate of Group
Dental Insurance.
*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.
***Maximum of 3 per family.
MAJOR RESTORATIVE LIMITATIONS The charges for Major
Restorative services will be Covered Dental Expenses subject to the
following:
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the denture or partial denture must replace a Natural Tooth extracted
while insured for Dental Benefits under this policy
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the fixed bridge (including a resin bonded fixed bridge) must replace
a Natural Tooth extracted while insured for Dental Benefits under this
policy;
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the replacement of a partial denture, full denture, or fixed
partial denture (including a resin bonded bridge), or the addition of
teeth to a partial denture if: (a) replacement occurs at least five years
after the initial date of insertion of the current full or partial denture
or resin bonded bridge; (b) replacement occurs at least five years after
the initial date of insertion of an existing implant or fixed bridge; (c)
replacement prosthesis or the addition of a tooth to a partial
denture is required by the necessary extraction of a Functioning
Natural Tooth while insured for Dental Benefits under this policy; or (d)
replacement is made necessary by a Covered Dental Injury to a partial
denture, full denture, or fixed partial denture (including a resin bonded
bridge) provided the replacement is completed within 12 months of the
injury;
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the replacement of crowns, cast restorations, inlays, onlays or other
laboratory prepared restorations if: (a) replacement occurs at least five
years after the initial date of insertion; and (b) they are not
serviceable and cannot be restored to function;
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the replacement of an existing partial denture with fixed
bridgework, only if upgrading to fixed bridgework is essential to the
correction of the person's dental condition; and
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the replacement of teeth up to the normal complement of 32.
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EXCLUSIONS
Benefits will not be paid for:
procedures which are not included in
the Schedule of Benefits; which are not medically necessary; which do not
have uniform professional endorsement; are experimental or investigational
in nature; for which the patient has no legal obligation to pay; or for
which a charge would not have been made in the absence of insurance;
any procedure, service, or supply which may not reasonably be expected to
successfully correct the patient's dental condition for a period of at least
three years, as determined by CompBenefits Insurance Company;
crowns, inlays, cast restorations, or other laboratory prepared restorations
on teeth which may be restored with an amalgam or composite resin filling;
appliances, inlays, cast restorations or other laboratory prepared
restorations used primarily for the purpose of splinting;
any procedure, service, supply or appliance, the sole or primary purpose of
which relates to the change or maintenance of vertical dimension; the
alteration or restoration of occlusion including occlusal adjustment, bite
registration, or bite analysis;
pulp caps, adult fluoride
treatments, athletic mouthguards; myofunctional therapy; infection control;
precision or semi-precision attachments; denture duplication; oral hygiene
instruction; separate charges for acid etch; broken appoint-ments; treatment
of jaw fractures; orthognathic surgery; completion of claim forms;
exams required by third party; personal supplies (e.g. water pik,
toothbrush, floss holder, etc.); or replacement of lost or stolen
appliances;
charges for travel time; transportation costs; or
professional advice given on the phone;
procedures performed by a
Dentist who is a member of Your immediate family;
any charges,
including ancillary charges, made by a hospital, ambulatory surgical center,
or similar facility;
charges for treatment rendered: (a) in a
clinic, dental or medical facility sponsored or maintained by the
employer of any member of Your family; or (b) by an employee of the employer
of any member of Your family;
any procedure, service or supply
required directly or indirectly to diagnose or treat a muscular, neural, or
skeletal disorder, dysfunction, or disease of the temporomandibular joints
or their associated structures;
charges for treatment performed
outside of the United States other than for emergency treatment. Benefits
for emergency treatment which is performed outside of the United States are
limited to a maximum of $100 (US dollars) per year;
the care or
treatment of an injury or sickness due to war or an act of war, declared or
undeclared;
treatment for cosmetic purposes. Facings on crowns or
bridge units on molar teeth will always be considered cosmetic;
any services or supplies which do not meet the standards set by the American
Dental Association or which are not reasonably necessary, or customarily
used, for dental care;
procedures that are a covered expense
under any other medical plan (established by the employer) which provides
group hospital, surgical, or medical benefits whether or not on an insured
basis;
a sickness for which the patient can receive benefits under
a workers' compensation act or similar law;
an injury that arises
out of or in the course of a job or employment for pay or profit;
charges to the extent that they are more than the Prevailing Fee. If the
amount of the Prevailing Fee for a service cannot be determined due to the
unusual nature of the service, CompBenefits Insurance Company will determine
the amount. CompBenefits Insurance Company will take into account: (a) the
complexity involved; (b) the degree of professional skill required; and (c)
other pertinent factors; or
orthodontic plan benefits for persons
19 years of age or older.
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PREDETERMINATION If Covered
Dental Expenses for a procedure are expected to be more than $200 it is
recommended that you send a Dental Treatment Plan in prior to beginning
treatment, send preauthorization to CompBenefits, P.O. Box 8236 Chicago, IL
60680�8236. You and/or your dentist will be notified of the benefits payable
based upon the Dental Treatment Plan. This brochure contains a brief
description of the plan. A complete description of the coverage, including
limitations on certain procedures is found in the Schedule of Benefits and
Certificate of Group Dental Insurance. Back to Top |