What if I have questions regarding the status of a claim or payment?
If you have any questions regarding your claim, please contact CIGNA at 800-577-0576 or the Fund Office.
How are payments made?
All payments for benefits under the Plan are made by CIGNA. You will receive a check from CIGNA unless you have assigned the benefit to the dentist. If you have assigned the benefit, payment will be made by CIGNA directly to the dentist.
Will I receive an Explanation of Benefits (EOB)?
Yes. You will receive a statement from CIGNA, delineating the specific services performed and amount(s) paid; regardless of to whom payment was made. Please review this for accuracy. Report any discrepancies to the UFT Welfare Fund.
Are benefits provided for the replacement of, or addition to, prosthetics?
Benefits are provided for the replacement of, or addition to prosthetic appliances only under the following circumstances:
1. when replacement of an existing partial or full removable denture, or fixed bridgework replaces missing natural teeth by a new partial or full removable denture, or by addition of teeth to an existing partial removable denture; or
2. when replacement of existing fixed bridgework replaces fixed bridgework, or by the addition of teeth to existing fixed bridgework; or
3. when replacement of an existing partial denture, which replaces missing natural teeth by new fixed bridgework but only when, as a result of the existing condition of the oral cavity, a professional result can be achieved only with bridgework.
Otherwise, the Covered Dental Expenses for the replacement of an existing denture are limited to the Covered Dental Expenses for a new denture.
With regard to 1, 2 and 3 above, satisfactory evidence must be presented that:
a. the replacement or addition of teeth is required
to replace one (1) or more missing natural teeth
extracted or accidentally lost after the existing
denture or bridgework was installed and while
the family member was covered under the plan;
and
b. the existing denture or bridgework was installed
at least five (5) years prior to its replacement,
whether or not benefits were paid for it by this
Dental Plan, and that the existing denture or
bridgework cannot be repaired, duplicated, or
made serviceable; and
c. the existing denture is an immediate temporary
denture that cannot be made permanent, and its
replacement by a permanent denture takes place
within twelve (12) months from the installation of
the immediate temporary denture.
4. when, in the case of replacement of an existing free standing crown, evidence satisfactory to CIGNA is presented that the existing crown cannot be repaired or made serviceable, whether or not benefits were paid for it under this Dental Plan.
What is not covered under the Scheduled Benefit Plan?
1. Charges made by a practitioner other than a dentist. Exception: a licensed dental hygienist may perform cleaning or scaling of teeth, if such treatment is rendered under the supervision and direction of the dentist.
2. Charges for services and supplies that are partially or wholly cosmetic in nature, including charges for personalization or characterization of dentures.
3. Charges for crowns, inlays, onlays, dentures, bridgework, or other prosthetic appliances, and the fitting thereof, which (a) were ordered under the plan, or (b) which were ordered while the individual was covered under the plan, but are finally installed or delivered to such individual more than thirty (30) days after termination of coverage.
4. Charges for the replacement of a lost or stolen prosthetic device.
5. Charges for any services or supplies that are for the correction or modification of an occlusion, including orthodontic treatment, except to the extent those benefits are provided for in the “Schedule of Covered Dental Expenses”.
6. Charges for any duplicate prosthetic device, or other duplicate device or appliance.
7. Charges for dentures, crowns, inlays, onlays, or bridgework intended to increase vertical dimension, or to diagnose or treat TMJ dysfunction or stabilize periodontally involved teeth.
8. Charges for precision or other elaborate attachments or features for dentures, bridgework, or any other dental appliances.
9. Charges for any services or supplies that are not specifically included as Covered Dental Expenses.
10. Charges that would not have been made if no benefit plan existed, or charges that neither you nor any of your dependents are required to pay.
11. Charges for services or supplies that are furnished, paid for, or otherwise provided for by reason of the past or present service, of any person in the armed forces of a government.
12. Charges for services or supplies which are paid for, or otherwise provided for under law of a government (national or otherwise), except where the payments or the benefits are provided under a plan specifically established by a government for its civilian employees and their dependents.
13. Charges for any dental treatment, services or supplies that are not recommended and approved by the attending dentist.
14. Charges for services or supplies which do not meet professionally recognized standards of quality, are not necessary for treatment of existing disease or injury, or are not appropriate treatment, taking into account the total currently existing oral condition.
15. Charges in excess of the allowances authorized by the Fund.
16. Charges for specialty orthodontic or interim appliances.