PPO
Preferred Provider Organization
Every member that has a DMO plan must assign?
What is a Dental Fund plan?
It is an employer-established Health Fund based product. It was established as a fund that pays for any eligible dental services a member receives in a given year.
Who did Aetna purchase in the year 2,000?
Prudential Insurance
CS Toolbar - DT&R - DSC Info
No
All members are required to obtain a referral before seeing a specialist, with the exception of this specialty.
Orthodontics (Braces)
Who determines the amount the fund will receive at the beginning of the plan year.
The employer determines the Dental Fund amount at the beginning of the plan year. Members can't make additional contributions.
What are the 3 dental products available with Dental 2,000?
Comprehensive Indemnity Dental
PPO Dental
DMO Dental
A caller is requesting to speak to a specific CSR. Where can I find the steps I must take?
CS Toolbar - DT&R - Workflow - Caller Requests A Specific CSR/QA (Someone who they have already spoken to)
What DR will give me information about Rental Networks?
DR 07-10
A DMO plan has NO?
deductible and calendar year maximum
Under an integrated Health Fund, the fund amount applies to?
Both dental and medical expenses
How is an emergency care covered under an EPP plan?
Emergency services will allow the dentist’s fee up to a $100 maximum (unless otherwise noted in the plan benefits due to state legislation or Plan Sponsor/employer request).
Where can I find the complete list of the ADA Codes?
CS Toolbar - e.policies - ADA Code Listing
What does it mean if a plan is integrated?
Integrated PPO Plans combine preferred and nonpreferred benefit expenses. Both preferred and nonpreferred expenses accumulate towards the combined benefit limits.
What is an office visit copay?
Office visit copayments are a set amount, usually $2, $5 or $10, that must be paid by the member regardless of the types of services being performed, with the exception of services from an Orthodontist.
If a member has a dental fund plan, and the service they received is a non-covered service.. will the fund pay it?
Not covered services by the plan, age restrictions, or services denied due to frequency limit could be payable under the fund due to plan exceptions. This requires the plan sponsor to select any exception services prior to the plan implementation.
Dental 2,000 FOC Comprehensive Dental pay benefits based on?
Recognized Charge or both Recognized Charge and a schedule of benefits
I need to fax the DMO office the eligibility form. Where can I find it?
CS Toolbar - Dental Network Tool (DNT) - Fax Elig Form
What is the difference between Preferred Benefits and Nonpreferred benefits.
*Preferred benefits can be a higher level of benefit coverage if the plan is an active PPO plan. When members receive care from a participating provider they receive the preferred (In-Network) benefit level for covered services. Claim reimbursement is based upon negotiated rates.
*Nonpreferred benefits can be a lower level of benefit coverage if the plan is an active PPO plan. When members receive care from a nonparticipating provider they receive the nonpreferred (Out-of-Network) benefit level for covered services. Nonpreferred benefits are similar to comprehensive dental benefits under Indemnity. Claim reimbursement is based upon Recognized Charges or scheduled benefits.
Please explain the 15th of the month rule.
If the member/dependents makes the change using the Aetna Member Website or if the member calls to make a change to their dentist prior to the 15th of the month, the effective date of the switch will always be the 1st of the next month.
If the member calls to make a switch after the 15th of the month, the effective date of the change will be the first of the month following the next month.
What does Base Plan Pays Then Fund Pays Member Responsibility
All fund dollars are initially released to meet the plan deductible. Once the plan deductible is met, the plan will pay benefits according to the plan rules, and any remaining fund dollars will only be used to pay covered expenses not reimbursed by the plan.
What makes an EPP unique?
it has no out-of-network benefits
A dentist contacts you to ask what documentation is required when submitting a claim for procedure code D6010.
CS Toolbar - e.policies - DR 08-01
Current dated full mouth pre-operative radiographs and/or panoramic radiograph ■
Extraction dates of teeth to be replaced
Date of prior prosthetic placement (fixed and/or removable dentures, if applicable)
Numbers of all missing teeth
Tooth number of proposed implants