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Medicare Part D


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-
to-month basis.

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

EXAMS

Cleanings/Prophylaxis:
3 per calendar year, including periodontal maintenance. Covered once every 6 months. This frequency includes all typed of exams, including emergencies.

Fillings:       
Covered once per 12 months.

Fluoride:
Covered once per 12 months, up to the age of 14.

Periodontal Maintenance:
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.

Posterior Composites:
Downgraded to the amalgam rate.

Prosthetic Replacement:
Covered once every 36 months. Considered for payment on seat date.

Root Canal Retreatment:    
Covered after 12 months.

Sealants:
Covered once per quadrant per lifetime, up to the age of 14.

Xrays:
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.

 

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Summary Plan Description & Supplements

Summary Plan Description - July 2013

Supplement #1 - Jul 2013
(Health Benefits Coverage of Spouses of Same Sex Marriages and Domestic Partners)

Supplement #2 - Jul 2013
(Benefits for Aqua Therapy)

Supplement #3 - Jul 2013
(Improved Coverage for Out-of-Network Emergency Services
Effective April 1, 2013)

Supplement #4 - Aug 2013
(Benefits for Genetic Testing)

Supplement #5 - Nov 2013
(Benefit Improvements)

Supplement #6 - Nov 2013
(Prescription Drug Improvement)

Supplement #7 - Nov 2013
(Health Reimbursement Arrangement (HRA) Forfeiture of Contributions Made Before Establishing or Re-Establishing Eligibility and Addition of an Opt-Out Feature)

Supplement #8 - Dec 2013
(Additional Benefit Improvements)

Supplement #9 - Mar 2014
(Additional Benefits)

Supplement #10 - Jul 2014
(HRA Election of Additional Contributions)

Supplement #11 - Aug 2014
(Mental Health Improvement)

Supplement #12 - Sept 2015
(New Dental Benefit)

Supplement #13 - Nov 2015
(Food Allergy Testing)

Supplement #14 - Nov 2015
(Dental Space Maintainers)

Supplement #15 - Nov 2015
(Dental Crowns Clarification)

Supplement #16 - Nov 2015
(Supplement Limitations of Action)

Supplement #17 - Feb 2016
(Health Reimbursement Arrangement (HRA) Claim Deadline)

Supplement #18 - Feb 2016
(Benefits for Contraceptive Drugs and Devices)

Supplement #19 - Feb 2016
(Temporomandibular Joint Dysfunction (TMJ))

Supplement #20 - Feb 2016
(No Assignment of Benefits)

Supplement #21 - Nov 2016
(Benefits for Home Health Services)

Supplement #22 - Nov 2016
(Benefits for Acupuncture)

Supplement #23 - Nov 2016
(Benefits for Gender Reassignment)

Summary of Benefits & Coverage 2014

Summary of Benefits & Coverage 2015

Updated Summary of Active Plan Benefits - Jan 2014
(Attachment for Supp #5 & #8))

Glossary of Health Coverage & Medical Terms - July 2013

Glosario de términos médicos y seguros de salud - July 2013

FORMS

$1800 Dental Benefit Summary

CIGNA Dental HMO Benefit Summary

Abreviated Schedule of Dental Benefits (January 1, 2017)

Southern California Pipe Trades Administrative Corporation | 501 Shatto Place, 5th Floor | Los Angeles | CA 90020 | (800) 595-7473 | Press Option "2" for Member Services | Outside US (213) 385-6161 | Fax (213) 383-0725