FREQUENTLY ASKED QUESTIONS FOR PROVIDERS
How do I know if the patient is eligible?
Eligibility can be obtained by calling 800-595-7473 and selecting Option 2. Eligibility is quoted on a month-
How do I join your network?
The Southern California Pipe Trades Health & Welfare Fund does not currently offer a network of dental providers. We are a self-funded indemnity plan with payments based on our dental fee schedule.
Does the patient have an out-of-pocket expense or an out-of-pocket maximum?
The patient is responsible for the difference between our dental fee schedule allowance and your usual and customary rate for each code billed.
Does the patient have a deductible?
The Plan has a deductible of $50.00 per calendar year. The family deductible is $150.00 per calendar year.
Is there a yearly maximum?
The Plan will cover 100% of our dental fee schedule, after deductible, up to $1,800.00 per patient per calendar year.
What is the percentage covered for basic, major and preventative services?
The Plan will cover 100% of our dental fee schedule for all services listed.
How do you coordinate benefits?
We follow standard coordination of benefits rules, not non-duplication rules.
May I file my claim electronically?
We do not accept electronic claims. Please submit a paper claim on the current ADA form.
Is Pre-Authorization mandatory?
No, it is not mandatory, but is suggested for claims over $300.00.
Are Occlusal Guards/Nightguards covered?
Covered if required due to bruxism.
Are Space Maintainers covered?
Covered with no age limit, for primary teeth only, subject to the following limitations:
- one space maintainer is covered per quadrant;
- a second space maintainer on the same arch will be covered up to the bilateral benefit;
- only one bilateral space maintainer is covered per arch; and
- space maintainers are covered only once per lifetime in a quadrant.
This is deducted from the orthodontic maximum.
Are prior extractions covered?
Yes, prior extractions are covered.
Is there a missing tooth clause under The Plan?
No, there is no missing tooth clause.
Are there any waiting periods under The Plan?
No, there are no waiting periods.
COMMON TREATMENT FREQUENCIES
3 per calendar year, including periodontal maintenance. Covered once every 6 months. This frequency includes all typed of exams, including emergencies.
Covered once per 12 months.
Covered once per 12 months, up to the age of 14.
Covered up to 3 times per calendar year and shares the frequency with the regular prophylaxis. Patient history must include ADA codes 4341 or 4342 to perform periodontal maintenance.
Periodontal Scaling and Root Planing:
Covered once every 12 months. Submission of the perio chart is required with claim. All 4 quadrants can be performed in one visit.
Downgraded to the amalgam rate.
Covered once every 36 months. Considered for payment on seat date.
Root Canal Retreatment:
Covered after 12 months.
Covered once per quadrant per lifetime, up to the age of 14.
Full mouth, bitewing and panoramic x-rays are covered once every 12 months each; they cannot be billed for on the same day.
COMMON ORTHODONTIC BENEFIT QUESTIONS
Are there Orthodontic benefits under The Plan?
The Plan will cover up to $600.00 per calendar year, deducted from the general dental maximum of $1,800.00 per calendar year.
Is there a lifetime maximum for Orthodontic benefits?
Yes, there is a $1,800.00 lifetime maximum benefit per patient.
Is there a monthly maximum for Orthodontic benefits?
The Fund will pay the Dentist’s monthly fee up to $200.00 per month, until the $600.00 per calendar year maximum is exhausted.
What information do I need on the initial claim?
The Dentist’s breakdown must include the initial fee, the monthly fee as well as the number of months the patient will be in treatment.
Will monthly payments be made automatically after the initial claim is submitted?
The Dentist must submit monthly claims, with the exact date the patient was seen.
We do not issue payment automatically.