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Benefits
DC 37 Health & Security Plan Benefits
Dental
Benefit
Please contact the Inquiry Unit at 212-815-1234 to
determine your eligibility for this benefit and your benefit plan allowances.
Members who are eligible for a full dental benefit will be covered for 100%
of the dental fee schedule. If you use a non-participating provider, you will
be responsible for any difference between the Plan's fee schedule and the dentist's
actual charges.
Members who are eligible for a partial dental benefit
will be covered for 75% of the dental fee schedule and will be responsible for
the additional 25%. If you use a non-participating provider, you will be responsible
for any difference between the Plan's fee schedule and the dentist's actual charges,
in addition to the 25% of the allowable amount.
In
all cases should you obtain treatment that is restricted, has a frequency limitation,
is a non-covered procedure or if you go over the yearly maximum, you will be responsible
for any additional costs incurred.The yearly maximum benefit is $1,700 per calendar
year, based on the Plan's fee schedule. In all circumstances, Plan rules regarding
restrictions, limitations, and annual dollar limit will apply.
Mandatory Pre-Authorization
Pre-authorization
is mandatory before beginning treatment for prosthetics (dentures and bridgework),
single crowns, extensive gum treatment, TMJ therapy, root canal therapy or orthodontics.
YOU MUST submit a Pre-Authorization Plan.
This pre-authorization is for
your benefit. You get a free second professional opinion to determine if the work
is necessary. In addition, you will have advance notice of the extent of the work
involved- dentally and financially.
YOU
MUST SUBMIT A PRE-AUTHORIZATION PLAN FOR THE ABOVE LISTED SERVICES OR YOUR CLAIM
WILL BE REJECTED.
On the appropriate form, available at the Plan
Office, your dentist will describe the proposed work, and attach x-rays to show
that the work is needed.
You and your dentist should complete the form
and send it to the Plan Office. The Plan Office reviews the pre-authorization
plan, then notifies you and your dentist if the intended work is covered and for
how much. THIS ASSUMES, OF COURSE, THAT YOU ARE ELIGIBLE FOR BENEFITS WHEN THE
WORK IS PERFORMED, and takes into consideration the Plan's rules and regulations
regarding yearly maximums and frequency limitations for certain procedures. There
are no appeals for proposed treatment (pre-authorization) that have been rejected
by the Plan. If the dentist disagrees with the treatment authorized in the pre-authorization
response, the dentist should write to the Professional Review Unit and send in
any additional information justifying why he/she thinks the procedure should be
done.
New Dental Claim Forms
The Dental Unit can accept both DC
37 Dental claim forms (pdf format*) as well as universal claim forms
from your dentist's office. DC 37 claim forms are available at the Plan office.
The form is a one-page claim form, with information about filing claims
on the back in both English and Spanish. The form has two sections, one to be
completed by the member and the second, to be completed by the dentist. All required
signatures are located at the bottom of the claim form. The member and
dentist sign only one box, whether the claim is for a Pre-Authorization or Claim
for Completed Services. For claims for completed services, the member must indicate
that the payment be made to either the member or dentist by checking the appropriate
box. You download
claim forms here (pdf format*) or request the forms be sent to you by
calling the Plan's Inquiry Unit at the Forms Only line at (212) 815-1531.
Claims -
If
treatment does not need pre-authorization, the member should submit the claim
form (pdf format*) signed by the member and the dentist with the proper
address within 30 days of completion of treatment. -
If
a pre-authorization was submitted, the claim for payment should be returned on
the computer generated pre-authorization form after the dentist inserts the dates
of treatment. The member and the dentist should sign the claim form. BEFORE THE
MEMBER SIGNS THE CLAIM FORM, HE/SHE SHOULD BE SURE THAT ALL THE PROCEDURES, SIGNED
FOR, WERE DONE. REMEMBER THAT MEMBERS WILL BE HELD RESPONSIBLE FOR ALL TREATMENT
BILLED WHETHER ACTUALLY PROVIDED OR NOT. IF THE PLAN IS BILLED, THE APPROPRIATE
RESTRICTION WILL BE PUT IN PLACE. If only a partial payment is requested, the
member still has to submit a claim on the same computer-generated form. A new
pre-authorization form will be generated by the computer, and sent to the member
and the dentist, for the rest of the work. -
If
information is missing from the claim relating to the treatment, or if additional
treatment was done that was not pre-authorized, the claim may be pended. The member
and the dentist will then be informed why the claim was not paid and the dentist
will be requested to provide us with the necessary information so that payment
can be made. -
When resubmitting a
claim, please submit original claim forms with original signatures - photocopies
of signatures and claim forms are not acceptable for payments. It's
the member's responsibility to make sure that the dentist completes and signs
his/her portion of the claim and that the form is submitted within 30 days after
the completion of work. All pre-authorizations and claims should contain:
-
Member's Social Security number -
Tax I.D. of the dentist -
Signatures
of dentist and member -
CDT 2007/2008 Codes -
Treatment descriptions, tooth #'s and quadrants -
Complete patient information If
any of the above information is omitted, the pre-authorization or claim cannot
be processed and will be returned to the member or dentist.
Continuation of Treatment
If you are terminated
from employment for any reason except total disability- (members receiving Disability
Benefits are eligible for Health & Security Plan benefits up to a maximum
of three months for part time benefits or six months for full time benefits, from
the date of their disability)- while you are having dental work done, the Plan
will continue to cover certain services* already begun up to 60 days after termination.
This is also true for your spouse and eligible dependents.
* Only
Orthodontics, prosthetics or root canal therapy.
Inquiries
For information relating to dental pre-authorizations and claims, you should
contact the Inquiry Unit at 212-815-1234.Effective 10/1/2001 increases were made
in the DC 37 Health & Security Plan's dental fee schedule. The increase in
reimbursement, both at the member and participating level, will apply to oral
surgery, bridges, dentures and endodontics. The yearly maximum benefit was increased
as well, from $1,500 to $1,700.
Guidelines
of the Plan's Dental Services
Regular
Examinations and Cleaning: Once every six months, measured from the date of
service, you (and eligible dependents) can have your teeth examined by a licensed
dentist to check for cavities and other dental or oral problems. You can also
have your teeth cleaned and scaled once every six months.
Diagnostic
X-Rays: You can have your whole mouth x-rayed as a double check on possible
dental problems once every two (2) consecutive calendar years. There is a $50
maximum x-ray benefit for the two years. This does not apply to x-rays necessary
to diagnose a specific disease or injury or to determine progress in its treatment.
Benefits will be available for any post operative x-rays (except in
root canal therapy) whenever it is requested by the Plan to help in an evaluation.
The amounts that will be paid for individual x-rays are listed in the Plan's Dental
Fee Schedule.
Fluoride Treatments: Once every six months, measured
from the date of service, your children (18 years of age and under) can receive
fluoride treatments to help prevent tooth decay.
Emergency Treatment:
You are covered for treatment to alleviate pain when a toothache occurs.
Fillings: To repair decayed teeth.
Extractions: And other
oral surgery covered as required.
Crowns (caps), Bridgework &
Dentures: Crowns, bridgework and dentures are not covered during the first
year of employment unless it is replacing a tooth, which was extracted while you
were a covered individual. Bridgework, dentures and crowns will not be replaced
before a five (5) year period has elapsed from the original date of placement.
If it becomes necessary to extract the abutment tooth of a bridge during this
five (5) year period, the Plan will only pay for the replacement of the tooth
providing it can be added to the existing appliance (an abutment tooth is the
tooth, which supports
the fixed or partial denture).
Root Canal
Therapy: Payment for root canal therapy is once in a lifetime per tooth.
Periodontia: Gum treatments and necessary periodontic care. If you
use the periodontal panel or receive periodontal care at one of the dental centers,
there is a $10 per quadrant co-payment for periodontal surgery.
Orthodontics:
Please contact the Plan office to determine your eligibility for this benefit.
Orthodontia coverage is available to members and all dependents covered as part
of the active full dental benefit. Orthodontia coverage is not available to members,
retirees or dependents covered for a partial dental benefit.Orthodontia coverage
is available to dependent children only as part of the retiree full dental benefit.
If you are eligible for an orthodontia benefit, the Plan will pay up to $1840
for this very important aid to dental health. It breaks down this way: The Plan
pays up to $400 for diagnosis and the orthodontic appliance, then up to $60 a
month for adjustments. The $1840 is a lifetime maximum for the orthodontia benefit
for treatment started after 10/01/01.
Orthodontia Benefit Dollars:
The lifetime maximum for orthodontia benefit is:
1) $1500 for work started
after January 1,1990 up to September 30, 2001.
2) For work started after October
1, 2001, the lifetime maximum is $1840.
The start date is the date the appliance
is inserted.
In all circumstances, Plan rules regarding restrictions,
limitations, and annual dollar limit will apply.
Coverage
Exclusions
What the Plan does not
pay for: -
In general, any dental
work begun before you become eligible for dental benefits will not be covered,
even if completed after you become eligible. For example, if a root canal was
opened before becoming eligible, the root canal therapy will not be covered even
if done at a later date. If you have a tooth prepared for a cap before becoming
eligible, the cap is not covered even if it is put on after eligibility is established. -
Benefits are not payable for more than one examination
and cleaning in any six consecutive months. -
The
Plan does not pay an additional fee for the completion of forms. -
Benefits are not payable for a prophylaxis rendered the
same day as a periodontal treatment. -
Benefits
for topical application of fluoride are not payable for persons over 18 years
of age. -
Fluoride treatments for
persons under 18 years of age are not payable more than once every six months. -
Occlusal adjustments are limited to one full mouth adjustment
every five years, effective January 3,1994. -
No
additional allowance will be provided to connect or disconnect units involved
in fixed bridgework. -
Benefits are
not payable for temporary crowns unless necessitated by an accidental injury to
natural teeth. -
A temporary restoration
(except when necessitated by accidental injury) is considered part of and is included
in the allowance for the final restoration. -
No
additional benefits will be provided for postoperative treatment. -
Payment is limited to: a) two pins per tooth, b) $55 filling
benefit per tooth. -
Benefits are
not payable beyond a maximum of $1700 per covered individual per calendar year. -
Benefits are not payable for the following services to
a covered individual, such as: (i) an appliance, or modification of an appliance,
for which an impression was made before the person became a covered individual,
or (ii) a crown, bridge or gold restoration, for which a tooth was prepared before
the person became a covered individual, or (iii) root canal therapy, for which
the pulp chamber was opened before the person became a covered individual. -
Benefits are not payable for a partial or full removable
denture or fixed bridgework if it involves replacement of one or more natural
teeth extracted prior to the employee being in a covered job title for a consecutive
12 month period, unless the denture or fixed bridgework also includes replacement
of a natural tooth, which (i) is extracted while the person is such a covered
individual and (ii) was not an abutment to a partial denture or fixed bridge installed
within the immediately preceding five years. -
Benefits
are not payable for a new partial or full removable denture or fixed bridgework,
or a crown or gold restoration, if it involves the replacement of a denture, bridgework,
crown or gold restoration which was inserted during the immediately preceding
five years. -
Benefits are payable
for a precision denture up to the maximum scheduled benefit allowable for a cast
or acrylic base partial denture with a gold or chrome lingual or palatal bar with
two clasps. However, crowns inserted as abutments for precision or semi-precision
attachment appliances and cast or acrylic based partial dentures are not covered
except where necessitated by either periodontics or restorative reasons. -
Adjustments to dentures and space maintainers are considered
part of the allowance if made within four months of installation. The relining
of an immediate denture will be considered after four months from the insertion
date. An office reline will be limited to once every twelve (12) months. A laboratory
reline will be limited to once every twenty-four (24) months. -
Any service not listed in the Plan's fee schedule will
be excluded except as follows: If a charge is incurred for a service not included
in the schedule, in connection with the dental care of a specific covered condition,
and if the schedule contains one or more services which, according to customary
dental practices, are in the Plan's opinion, appropriate for the dental care of
that condition, then a charge for the least expensive of such services as are
included in the Schedule will be considered to have been incurred in lieu of the
charge actually incurred. -
Expenses
incurred after the termination of a person's coverage are not reimbursable except
as applicable under the Continuation of Treatment Provision. -
Charges in excess of the scheduled fee shown in the Plan's
benefit schedule. -
Charges for procedures
rendered before a person becomes eligible for benefits. -
A service not reasonably necessary, or not customarily
performed, for the maintenance of the patient's health. -
A service furnished a person for cosmetic purposes, unless
necessitated as a result of an accidental injury sustained while the person was
a covered individual. -
Facing on
crowns, or pontics, which are posterior to the first molar are considered cosmetic
and are excluded in accordance with paragraph 24 above. -
Any employment related disease or injury to the teeth,
which is covered by any Workers' Compensation law, occupational disease law, or
similar legislation. -
A service or
supply (i) furnished by or for the U.S. Government, (ii) furnished by or for any
other government unless payment is legally required, or (iii) to the extent any
benefit is provided by any law or government program under which the person is
or could be covered. -
Charges covered
by another group dental insurance plan. -
Replacement
of lost or stolen appliances. -
Any
dental service which is not furnished by a licensed dentist, unless performed
by a licensed dental hygienist under the supervision of a dentist or is an x-ray
ordered by a licensed dentist. -
Services
covered by any other medical or surgical benefit or insurance program. -
Charges for oral hygiene instruction, dietary planning,
etc. -
Dental supplies, including,
but not limited to, toothbrushes, toothpaste, mouthwash, water-piks, etc. are
not covered by the dental benefit. -
Payment
for periodontal surgery is restricted to once every five years. Each quadrant
will be considered individually. Dental
Centers
In
addition to using any licensed dentist or a dentist from the Plan's list of Participating
Panel Dentists, a member and/or dependents may also obtain treatment at either
of the two dental centers. The same Plan rules regarding: restrictions, limitations
and/or annual dollar limit will also apply. The individual who obtains treatment
at the Plan's Centers will be required to comply with the policies and regulations
established by the Center for its patients.
Active and retired members
covered by the DC 37 New York Public Library Health and Security Plan Trust and
the DC 37 Cultural Institutions Health and Security Plan Trust are not eligible
for dental services at 115 Chambers Street and 186 Joralemon Street.
Dental Center Policies
JORALEMON DENTAL SERVICES, P.C.
| Manhattan
Center
115 Chambers Street
New York, NY 10007
(212) 766-4440 |
Brooklyn Center
186 Joralemon Street
Brooklyn, NY 11201
(718) 852-1400 | The following is a statement
of the policies of the Dental Centers. This policy statement is distributed to
each patient at his or her initial appointment. It is expected that each patient
will sign this statement before dental treatment begins.
DC 37 Health
& Security Plan Rules and Regulations limit your Dental Benefits to $1,700
per year based on the Plan's fee schedule. Expenses indicated on your Explanation
of Benefits (EOB) Statement as "Balance Due" are the member's responsibility,
whether or not you were informed prior to treatment. To avoid problems, please
discuss your treatment with your Dentist or Treatment Plan Coordinator.
When your first appointment is scheduled, you will be assigned to a general dentist.
Due to the volume of patients seen at the Center, it is not feasible to have patients
select their own dentist. The dentist will refer the patient to the hygienist.
If necessary, specialty care will be provided for active patients of the Centers.
All visits are by appointment only. Emergency visits are also by appointment
and are not treated on a walk-in basis. If you have an emergency, you must call
the Center early in the day. The screening dentist will advise you how to proceed.
The Centers render limited treatment on a case by case basis to patients
who have implants.
No-Shows - A patient
will be considered a "no-show" if s(he) fails to appear for a scheduled
appointment, or gives the Center less than 24 hours notice to cancel an appointment.
If three (3) or more no-shows occur, we will ask you to seek dental treatment
outside of the Center. If you are a no-show two (2) or more times for a Specialist
appointment, we will also ask you to seek treatment outside of the Center.
Lateness - Patients are seen by appointment only and time is allocated
based upon the procedure(s) to be completed. If a patient is late for his or her
appointment, we may not have sufficient time to do the scheduled work. In these
cases, we reserve the option to reschedule your appointment. Habitual lateness
will be treated as a no-show.
Cancellations - A minimum of 24-hours
notice is required for an appointment to be cancelled. Anything less than 24 hours
notice will be considered a no-show.
Maintaining your status as
an active patient requires your cooperation. The Center provides comprehensive
general dentistry and recommends that patients return each year for a dental check
up. If more than two years lapse, you will not be given an appointment until you
again place your name on the waiting list. We do not co-treat patients who are
in active dental treatment outside of the Center, except for orthodontics.
We offer these explanations of our policies to assist you. It is not possible
for us to address each individual's specific circumstances. You are encouraged
to ask questions for further clarification.
*Download
Acrobat Reader to view and print PDF files.
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