|Click here for the list of participating Dentists|
You will be paid up to the scheduled allowance for dental work furnished while you or an eligible dependent is covered, up to the maximum for the procedure listed in the dental schedule. In addition, if you use one of the participating dentists and FASCC Benefit Fund is the primary carrier, the fees listed in the dental schedule will be accepted as payment in full for covered services.
The following conditions must be met for benefits to be payable:
Maximum Amount Payable: The maximum amount payable for each covered active member and his or her dependents for covered dental services will be $2,250 in any plan year (September 1st to August 31st) exclusive of orthodontic, implant and periodontic services which have separate maximums. The yearly maximum per person for covered periodontic work is $2,000. The lifetime maximum per person for orthodontia is $5,991 However, if orthodontic work commenced prior to 9/1/06, the lifetime maximum will be calculated using the fee schedule in effect on the date services are commenced. The lifetime maximum per person for implants is $3,500 ($2,000 for the 1st and $1,500 for the second).
The maximum for covered retirees in the Basic Plan is $500 per plan year (September 1st to August 31st) for the retiree and his or her eligible dependents combined. The maximum amount payable for each covered retiree and his or her dependents in the enhanced plan for covered dental services is $2,000 per plan year. The retiree yearly maximums include periodontal, implant and orthodontial work.
Pre-Determination of Benefits: If your course of treatment is expected to cost more than $600, your dentist is required to complete a pre-determination request on the dental claim form and submit it with a properly mounted set of x-ray films for review by the Fund's Consultant Dentist. Pre-determination by the Fund's Consultant Dentist is limited to the approval of the course of treatment proposed; it does not include approval of payment for services not covered under the Dental Plan, the patient's eligibility or guaranteed payment. Completed treatment amounting to $1,000 or more may require examination of the patient by the Fund's Consultant Dentist before payment is made. Your dentist should be familiar with this procedure. This process assures that both you and your dentist will know in advance what services are covered and just what part of the dentist's charges the FA Benefit Fund would pay.
Pre-determination is not intended to interfere with your dentist's professional judgment or to delay your dental care. Rather, this process permits a review of the proposed treatment in advance and allows for the resolution of any questions before, rather than after, the work has been done.
The FA Benefit Fund has the right to request that a patient undergo an oral examination to verify the treatment that is recommended in the pre-determination review.
Failure to comply with the pre-determination rules will result in forfeiture of benefits.
Alternate Benefit Provision:
When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by the Fund's Consultant Dentist to be best suited to your condition by accepted standards of dental practice. If two services would both provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the Fund will reimburse up to the scheduled allowance of the less expensive treatment.
The attending dentist and the patient may still proceed with the original treatment plan regardless of the Fund's determination. However, reimbursement will be made at the level of the alternative.
For example, payment for a crown may not be made if an acceptable professional result can be obtained by filling the tooth. Payment will then be made as if the tooth were filled.
In order to obtain benefits, request the necessary dental claim form from the Fund Office. Upon completion of treatment, have the dentist complete his or her portion of the claim form. You should then complete your portion of the claim form and mail it to the Third Party Administrator. If prolonged dental treatment is required, you should periodically submit claim forms to the Third Party Administrator for that portion of the treatment which has been completed. Payment of the claim will be made directly to you unless you use a participating dentist, then the payment will be made to the dentist.
Participating Dentist Program:
The FA Benefit Fund provides for free choice of dentists. However, the Fund has made arrangements with many dentists who accept the fees listed in the dental schedule as payment in full when FASCC Benefit Fund is the primary carrier. If you use a participating dentist and the Fund is the primary carrier, you will not have to pay for any services listed in the schedule up to the plan maximums. Payments will be made by the Fund directly to the dentist.
Participating dentists may charge you for services not covered by the plan if the annual maximum has been reached or the frequency limitation has been exceeded.
Dentists who specialize in orthodontia, periodontia, endodontia or oral surgery are listed separately from general dentists. This list will be revised from time to time by the Fund.
Click here for the list of participating dentists which provides the names, addresses and telephone numbers of the dentists who are currently participating with the Fund's dental plan. These dentists have agreed to provide covered dental procedures at no out-of-pocket expense to Fund members and their eligible dependents. The list is provided as an informational service only for the convenience of covered members and eligible dependents. The Fund does not recommend the services of any particular dentist. The participating providers have been selected because they have agreed to accept the Fund's fee schedule as payment in full for covered services. If you or your eligible dependents are charged for any covered services by a participating provider, do not pay the charge and contact the Fund Office immediately. The Fund requests that you report any irregularities, including rudeness, unsanitary conditions and difficulty in obtaining appointments at convenient hours, to the Fund Office.
Limitations and Exclusions