What is the Direct Reimbursement Program?
When you utilize a non-participating dentist, you may be required to pay for the full cost of the service and then submit a claim for payment. Reimbursement is made according to the scheduled amount or the actual charge, whichever is less.
What is a Pre-Treatment Estimate and when is it required?
A pre-treatment estimate is an advance notice of dental treatment that should be submitted before treatment is commenced in order to determine what benefits are available. A pre-treatment estimate is required for inlays or onlays, crowns, laminate veneers, bridgework, dentures, periodontal surgery or when expenses for services provided in a ninety (90) day period will exceed $500.
What is an Alternate Course of Treatment?
Due to the element of choice involved in the utilization of many dental services, situations frequently arise where two or more methods of treatment for a particular dental condition could be used; each of which may produce a desirable, professional result. If an equally effective procedure is available, which is also less costly, the allowance to be reimbursed will be based on this alternate course of treatment. Therefore, should you elect to follow the original course of treatment, you will be responsible for any charges that exceed the allowances for the Alternate Course of Treatment.
How are benefits obtained under the Scheduled Benefit Plan?
You can obtain benefit payments for services rendered by participating or non-participating dentists only if you file the required dental claim form with Connecticut General Life Insurance Company (hereinafter referred to as “CIGNA”) as described below.
The UFT Scheduled Benefit Plan is administered
by
Connecticut General Life Insurance Company
(CIGNA),
P. O. Box 182531, Chattanooga, TN 37422-7531
800-577-0576
www.mycigna.com
A. Dental Claim Form
The UFT Welfare Fund Dental Claim Form is used for
two different purposes. Indicate by checking the appropriate
box on the form whether it is a Pre-Treatment Estimate or
a Payment Claim.
You should take a dental form with you when you first visit the dentist, and for each new course of dental treatment. Participating dentists will have their own form.
B. Using the Dental Claim Form
1. Submission of Form
When submitting the Dental Claim Form, you must complete
all relevant items in the Member Information section.
If not applicable, disregard patient and spouse information.
The Authorization to Release Information must always be signed whether the form is a Pre-Treatment
Estimate or a Payment Claim.
The dentist completes the Dentist Information section, including patient name. The dentist must sign the form. In lieu of completing this form, the dentist may attach his or her own standardized form to the UFT Welfare Fund Dental Form, provided that all required information, including the procedure codes, and the dentist’s signature appear.
2. Assignment of Benefits
The benefits to which you are
entitled will be paid to you unless you assign them. Sign
the “Authorization to
Assign Benefits” line if you wish payment to be sent
directly to your dentist (payment to SIDS participating
dentists is automatically assigned.) If you assign benefits,
you will be notified of the payments made so that you
know the portion of the bill not covered by this plan.
3. Pre-Treatment Estimate
A Pre-Treatment Estimate (which is an Advance Notice of
Dental Treatment) may be submitted along with Pre-
Treatment X-rays when the dental course of treatment
includes one or more of the following:
a. Periodontal Surgery
b. Inlays or Onlays
c. Crowns
d. Bridgework
e. Dentures
f. Laminate veneers
g. The expense for services provided in a ninety
(90) day period would exceed $500.
The Pre-Treatment Estimate Form must include all services to be provided in the course of treatment within a ninety (90) day period.
The completed Pre-Treatment Estimate Form, signed by you and your dentist, must be submitted to CIGNA before treatment is commenced in order to determine what benefits are available.
You and your dentist will each receive an Explanation of Benefits (EOB) from CIGNA delineating the services authorized.
NOTE: The Pre-Treatment Estimate only authorizes the work to be performed. To obtain benefits, a Payment Claim must be submitted after the work has been performed listing dates of service. No payment will be made if the patient is not eligible when services are rendered.
4. Periodic Submission of Claims.
Upon completion of treatment, a complete Payment
Claim Form must be submitted to CIGNA with appropriate
X-rays. If treatment continues over a long period of
time, your dentist may wish payment as the work progresses.
To be reimbursed on an on-going basis your dentist
can periodically file a Payment Claim Form, indicating
the work that has been performed to date, and the
charges. This process can be repeated during the duration
of treatment.
5. Important Information Regarding Claim Form.
The Payment Claim Form must be submitted within one
(1) year of the date of service. Be sure to sign the claim
form. Remember, it is the member’s responsibility to
ensure that all claims are submitted in a timely manner.
Claims submitted more than one (1) year after completion
of treatment will not be honored for payment.
Be sure to inspect the claim before it is submitted to ensure that the listed services were actually performed. Please be advised that your signature authorizes reimbursement for all dental procedures listed.
NOTE: Pre- and post-treatment X-rays must be submitted with the Payment Claim Form for root canal therapy and non-routine extractions.