Section 7 General Exclusions – Things We Do Not Cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover
it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition.
We do not cover the following:
Plan Exclusions
•
Services which are covered under Medicare, worker’s compensation or employer’s liability laws.
•
Services which are not necessary for the patient’s dental health as determined by the Plan.
•
Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as
determined by the Plan.
•
Oral surgery requiring the setting of fractures or dislocations.
•
Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or
development malformations where, in the opinion of the Plan, such services should not be performed in a dental office.
•
Dispensing of drugs.
•
Hospitalization for any dental procedure.
•
Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or
undeclared.
•
Replacement due to loss or theft of prosthetic appliance.
•
Procedures not listed as covered benefits under this Plan.
•
Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan
(with the exception of out-of-area emergency dental services).
•
Services related to the treatment of TMD (Temporomandibular Disorder).
•
Services performed by a Participating Specialist without a referral from a Participating General Dentist (with the exception
of orthodontics).
•
Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth.
•
Plaque control programs, oral hygiene instruction, and dietary instructions.
•
Nitrous oxide and oral sedation.
Plan Limitations
•
Two (2) evaluations are covered per calendar year including a maximum of one (1) comprehensive evaluation. All oral
evaluations will be considered integral when provided on the same date of service by the same dentist.
•
One (1) problem focused exam is covered per calendar year, per patient.
•
Two (2) teeth cleanings (prophylaxis) are covered per calendar year, per patient (one (1) additional cleaning is covered
during pregnancy and for diabetic patients). Periodontal scaling in the presence of gingival inflammation is considered to
be a routine prophylaxis and paid as such.
•
Two (2) topical fluorides or fluoride varnishes are covered per calendar year, per patient.
•
Two (2) bitewing x-rays are covered per calendar year, per patient.
•
One (1) set of full mouth x-rays or panoramic film is covered every three (3) years, per patient.
•
One (1) sealant per tooth is covered per 36 months, up to age 18 (limited to permanent 1st and 2nd molars). Sealants with a
restoration on same date of service are considered integral.
•
Distal shoe space maintainer limited to once per lifetime.
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•
Replacement of a filling is covered if it is more than two (2) years from the date of original placement.
•
Replacement of a bridge, crown or denture is covered if it is more than five (5) years from the date of original placement.
•
Crown, implant and bridge fees apply to treatment involving five (5) or fewer units when presented in a single treatment
plan. Additional crown, implant or bridge units, beginning with the sixth unit, are available at the provider’s Usual,
Customary, and Reasonable (UCR) fee, minus 25%.
•
One (1) relining and rebasing of dentures is covered every 36 months, per patient.
•
Retreatment of root canal is covered if it is more than two (2) years from the original treatment.
•
Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of
root canal therapy.
•
One (1) root planing or scaling is covered every 24 months per quadrant, per patient. Periodontal scaling and root planing
provided within 24 months of periodontal scaling and root planing, or periodontal surgical procedures, in the same area of
the mouth is not covered.
•
Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation and in lieu
of a covered D1110/D1120, limited to once per two years.
•
One (1) full mouth debridement is covered per lifetime, per patient.
•
Procedure Code D4381 is limited to one (1) benefit per tooth for three (3) teeth per quadrant or a total of 12 teeth for all
four (4) quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater.
•
One (1) periodontal surgery of any type, including any associated material, is covered every 36 months per quadrant or
surgical site.
•
Periodontal maintenance after active therapy is covered two (2) times per calendar year, within 24 months after definitive
periodontal therapy.
•
Stainless steel crowns (D2930, D2931) are covered through age 14, or when placed as a result of accidental injury and one
per tooth, per lifetime.
•
Onlays, crowns, and posts and cores for members 12 years of age or younger are excluded from coverage, unless pre-
approved by the Plan. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core.
Posts are eligible only when provided as part of a crown buildup or implant and are considered integral to the buildup or
implant.
•
Fixed partial dentures, buildups and posts and cores for members under 16 years of age are not covered unless approved by
the Plan.
•
Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival
flap procedure are not covered.
•
Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth.
•
Surgical revision procedure (D4268) is considered integral to all other periodontal procedures.
•
One (1) scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of
the implant surfaces, without flap entry and closure, per two (2) years.
•
Coronectomy, intentional partial tooth removal, one (1) per lifetime.
•
Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless approved by the Plan.
•
Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in
connection with a covered procedure(s) when determined to be medically or dentally necessary for documented
handicapped or uncontrollable patients or justifiable medical or dental conditions
•
Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for
the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD). Occlusal guards are
limited to one (1) per 12 consecutive month period.
•
Athletic mouth guards are limited to one (1) per 12 consecutive month period.
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•
Teledentistry, synchronous (D9995) or asynchronous (D9996), limited to two (2) per calendar year (when available).
The Invisalign system is a discounted benefit that applies to D8070, D8080 and D8090. Additional costs incurred will
become the patient’s responsibility.
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Section 8 Claims Filing and Disputed Claims Processes
For in-network services, there are no claims for you to file.
This plan does not offer an out-of-network benefit. If you see an out-of-network provider
for emergency services, the claim (a standard ADA claim form) should be submitted to:
Dominion Dental Services, Inc.
P.O. Box 1126
Elk Grove Village, IL 60009
If you see an international dentist for emergency services, the provider or member should
submit a claim form with the following information: name of the country in which the
work was performed, the dentist’s name, the American Dental Association code(s), the
tooth number(s) and the date(s) of service. Claims must be submitted in U.S. dollars and
mailed to the address shown above.
How to File a Claim for
Covered Services
For emergency and international claims, you have one year from the date of service to file
your claim.
Deadline for Filing Your
Claim
Follow this disputed claims process, if you disagree with our decision on your claim or
request for services. The FEDVIP law does not provide for OPM to review disputed
claims.
Disputed Claim Steps
1 Ask us in writing to reconsider our initial decision. You must submit a formal written
statement to our Member Services Department c/o Dominion Dental Services, Inc. at: 251
18th Street South, Suite 900 Arlington, VA 22202 within one (1) year from occurrence of
the events upon which the grievance is based, and must contain a statement of the action
requested, your name, address, telephone number, Member number, signature and the
date.
2 We have 60 days from the date we received your request to render a decision to either
pay or deny the claim and communicate such decision back to you. However, if the
grievance involves collection of information from outside our service area, an additional
thirty (30) days will be allowed for processing.
3 If the dispute is not resolved through the reconsideration process, you may request a
review of the denial. You must request reconsideration by the Grievance Panel within
sixty (60) days after receipt of the initial grievance written decision by submitting a
written request to the our Member Services Department c/o Dominion Dental Services,
Inc. 251 18th Street South, Suite 900 Arlington, VA 22202.
4 If you do not agree with our final decision, you may request an independent third party,
mutually agreed upon by us and OPM, review the decision. The decision of the
independent third party is binding and is the final review of your claim. To request a
third-party review, you must submit a written request to our Member Services Department
c/o Dominion Dental Services, Inc. at: 251 18th Street South, Suite 900 Arlington, VA
22202.
Disputed Claims Process
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Section 9 Definitions of Terms We Use in This Brochure
The maximum annual benefit that you can receive per person. This plan does not have an
annual benefit maximum.
Annual Benefit
Maximum
Federal retirees (who retired on an immediate annuity), and survivors (of those who
retired on an immediate annuity or died in service) receiving an annuity. This also
includes those receiving compensation from the Department of Labor’s Office of
Workers’ Compensation Programs, who are called compensationers. Annuitants are
sometimes called retirees.
Annuitants
The enrollment and premium administration system for FEDVIP.
BENEFEDS
Covered services or payment for covered services to which enrollees and covered family
members are entitled to the extent provided by this brochure.
Benefits
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations,
sealants and x-rays.
Class A Services
Intermediate services, which include restorative procedures such as fillings, prefabricated
stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
Class B Services
Major services, which include endodontic services such as root canals, periodontal
services such as gingivectomy, major restorative services such as crowns, oral surgery,
bridges and prosthodontic services such as complete dentures.
Class C Services
Orthodontic services.
Class D Services
Copay or copayment is a fixed amount of money you pay directly to the dentist when you
receive covered services.
Copay
Treatment due to injury, accident or severe pain requiring the services of a dentist which
occurs under circumstances where it is neither medically or physically possible for you to
be treated by an assigned plan provider.
Emergency Services
The Federal employee or annuitant enrolled in this plan.
Enrollee
Federal Employees Dental and Vision Insurance Program.
FEDVIP
The standards set by the American Dental Association or which are customarily used for
dental care. Dominion Dental reserves the right to determine the level of necessary
treatment.
Generally Accepted
Dental Protocols
The exclusion of any service or supply rendered to replace a tooth lost prior to the
effective date of coverage. When the procedure/appliance is to replace only the tooth lost
prior to the member’s effective date, the procedure/appliance is not covered. When the
missing tooth is repaired in conjunction with other extractions after the effective date, the
procedure/appliance is covered.
Missing Tooth Clause
The amount we use to determine our payment for out-of-network services.
Plan Allowance
Any disease or condition of the teeth or supporting structures which existed on the
effective date of coverage.
Preexisting Condition
Dominion Dental Services, Inc.
We/Us
Enrollee or eligible family member.
You
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Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance
Program premium.
Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
•
Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your
providers, plan, BENEFEDS, or OPM.
•
Let only the appropriate providers review your clinical record or recommend services.
•
Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
•
Carefully review your explanation of benefits (EOBs) statements.
•
Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or
service.
•
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 855-836-6337 and explain the situation.
•
Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
- Your child over age 22 (unless he/she is disabled and incapable of self- support).
If you have any questions about the eligibility of a dependent, please contact BENEFEDS.
Be sure to review Section 1, Eligibility, of this brochure prior to submitting your enrollment or obtaining benefits.
Fraud or intentional misrepresentation of material fact is prohibited under the plan. You can be prosecuted for fraud
and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services
for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when
you are no longer eligible.
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Summary of Benefits
•
Do not rely on this chart alone. This page summarizes specific expenses we cover; please review the individual sections
of this brochure, for more detail.
•
If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS
(1-877-888-3337), TTY number 1-877-889-5680.
Benefit
You Pay:
High Option Benefits
Class A (Basic) Services – preventive and diagnostic
Copay
Class B (Intermediate) Services – includes minor
restorative services
Copay
Class C (Major) Services – includes major
restorative, endodontic, and prosthodontic services
Copay
Class D Services – orthodontic
No Lifetime Maximum
Copay
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Rate Information
How to find your monthly and bi-weekly rates:
• In the first chart below, look up your state or zip code to determine your Rating Area.
• In the second chart below, match your Rating Area to your enrollment type and plan option.
Premium Rating Areas by State/Zip Code (first three digits)
State
3 Digit Zip Code
Rating Area
State
3 Digit Zip Code
Rating Area
DC
Entire State
4
PA
173-174
4
DE
Entire State
5
PA
189-196
5
MD
206-212, 214, 217
4
PA
Rest of State
1
MD
219
5
VA
231-232, 238
3
MD
Rest of State
2
VA
201, 220-227, 233-237
4
NJ
080-084
5
Monthly Rates
Rating
Area
High Option
Self Only
High Option
Self Plus One
High Option
Self and
Family
Standard
Option Self
Only
Standard
Option Self
Plus One
Standard
Option Self
and Family
1
$22.17
$44.33
$66.50
$13.02
$26.04
$39.07
2
$22.97
$45.96
$68.92
$13.59
$27.17
$40.76
3
$24.14
$48.30
$72.43
$15.15
$30.31
$45.46
4
$28.08
$56.18
$84.26
$18.07
$36.14
$54.21
5
$32.98
$65.98
$98.95
$19.26
$38.55
$57.81
Bi-Weekly Rates
Rating
Area
High Option
Self Only
High Option
Self Plus One
High Option
Self and
Family
Standard
Option Self
Only
Standard
Option Self
Plus One
Standard
Option Self
and Family
1
$10.23
$20.46
$30.69
$6.01
$12.02
$18.03
2
$10.60
$21.21
$31.81
$6.27
$12.54
$18.81
3
$11.14
$22.29
$33.43
$6.99
$13.99
$20.98
4
$12.96
$25.93
$38.89
$8.34
$16.68
$25.02
5
$15.22
$30.45
$45.67
$8.89
$17.79
$26.68
2018
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Document Outline - Dominion Cover
- 12771-Dominion
- DominionRates
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