Dental Benefits

Click here for the list of participating Dentists

Dental Fee Schedule

 

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:

  • the claimant must be eligible for benefits at the time expenses are incurred;
  • the expense is incurred when the service is performed, except in the case of:
    • dentures - when the final impression is taken;
    • crown or fixed bridgework - when preparation of the tooth is begun;
    • root canal therapy - when work on the tooth is completed;
  • no changes have been made in the plan prior to the performance of the service that would change the allowance;total benefit payments for all treatment of a patient must not exceed the plan maximums;
  • the allowance may be reduced by coordination of benefits as applicable.

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).
Note: All plan maximums are based on The Fund's Schedule of Allowance.

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.

Obtaining Benefits: 

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

  • Covered dental expenses shall not include expenses incurred for:
  • Instruction for plaque control;
  • Oral hygiene instruction;
  • Bite registrations;
  • Experimental or investigational dental services;
  • Any services, supplies, or treatment unless prescribed by a legally qualified dentist or physician;\
  • Services rendered prior to the patient becoming eligible for benefits;
  • Any dental procedure performed wholly or substantially for cosmetic reasons or without respect to congenital mouth form;
  • Replacement of existing denture or partial denture more than once every five years;
  • Placement of existing crown or fixed bridge more often than once every five years;
  • Crowns, inlays, dentures bridgework or other prosthetic appliances installed or delivered more than 30 days after termination of coverage;
  • Charges for crowns, inlays, dentures, bridges or other appliances to increase vertical dimension or reduce occlusion;
  • Charges for multiple abutting of teeth or crowns, or teeth installed for clasping purposes only, or crowns and/or inlays installed as multiple abutments and splints to augment periodontal treatment;
  • Duplicate prosthetic appliances;
  • A prosthetic appliance, fixed or removable, used as an adjunct to periodontal care, unless it replaces a missing tooth;   
  • Charges for temporary crowns (unless tooth is fractured and only on anterior teeth), implants and bridges or dentures involving implants, or for temporary dental services which will be considered an integral part of the final dental service rather than a separate service;
  • Dental service performed by a dentist in which the Fund experiences an instance of unsatisfactory documentation or recording of services which are deemed detrimental to the Fund or the patient;
  • Most inclusive periodontal service includes all other services performed on the same date, in the same area and payment will be make for the all-inclusive service only; e.g., osseous surgery (ADA and 4260) and gigivectomy (ADA code 4210) performed on the same date, payment will be made for the all-inclusive osseous surgery only;
  • Any benefit that is claimed after a period that exceeds one year from the completion of the dental services;
  • Replacement of a lost or stolen appliance;
  • Dental supplies or services for which benefits are provided at a Veteran's Administration Hospital or Clinic, or for dental supplies or services  related to injury or disease covered by any Workers' Compensation law , or charges for expenses which are reimbursable through "no fault" automobile insurance;
  • Dental supplies or services furnished by or for the United States Government or any other local governmental agency or where reimbursement is made elsewhere;
  • Services where a charge is not incurred or payment is not required;
  • Services performed by a member of your or your spouse's spouse's immediate family, unless proof of payment is provided for those services.
  • Dental services or supplies not listed or not consistent with the Schedule of Allowance unless the Fund reviews the services and accepts the expenses as covered dental expenses.  The covered dental expense for such services will be determined by the Fund and will be consistent with those listed in the Schedule of Allowance.