You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options.  You can also select from several nationwide vision plans.  You may enroll in a dental plan or a vision plan, or both.  Some TRICARE beneficiaries may not be eligible to enroll in both.  Visit www.opm.gov/dental or
www.opm.gov/vision for more information.

You enroll online at www.BENEFEDS.gov.  Please see Section 2, Enrollment, for more information.

If you sign up for a dental and/or vision plan during the 2024 Open Season, your coverage will begin on January 1, 2025.  Premium deductions will start with the first full pay period beginning on/after January 1, 2025.  You may use your benefits as soon as your enrollment is confirmed.

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

Each year, an open season will be held, during which you may enroll or change your dental and/or vision plan enrollment.  This year, open season runs from November 11, 2024 through midnight EST December 9, 2024.  You do not need to re-enroll each open season unless you wish to change plans or plan options; your coverage will continue from the previous year.  In addition to the annual open season, there are certain events that allow you to make specific types of enrollment changes throughout the year.  Please see Section 2, Enrollment, for more information.

FEDVIP abides by the Current Dental Terminology (CDT) codification system in accordance with standards set by the American Dental Association (ADA).

Current Dental Terminology (CDT), Copyright © American Dental Association. All rights reserved.

If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program, the Postal Service Health Benefits (PSHB) Program, or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP.  Enrollment in the FEHB Program, PSHB Program or a Health Insurance Marketplace (Exchange) plan is not required.

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to work 130 hours per calendar month for at least 90 days. In addition, certain firefighters hired under a temporary appointment and intermittent emergency response personnel are eligible to enroll in FEDVIP. The employing agency must determine and notify these employees of their eligibility.

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee. There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB/PSHB Program. 

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when you begin to receive your annuity.

Advise BENEFEDS of your new payroll office number. 

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components, including “gray-area” retirees under age 60 and their families are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22.  This includes legally adopted children and recognized natural children who meet certain dependency requirements.  This also includes stepchildren and foster children who live with you in a regular parent-child relationship.  Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.  FEDVIP rules and FEHB/PSHB rules for family member eligibility are NOT the same.  For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in your legal custody by a court.  Children include legally adopted children, stepchildren, and pre-adoptive children.  Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity. 

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB/PSHB eligibility or receipt of an annuity or portion of an annuity:

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB/PSHB Temporary Continuation of Coverage (TCC) enrollees
• Anyone receiving an insurable interest annuity who is not also an eligible family member.
• Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP). 

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.gov) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically. Please Note:  Your plan's premiums may change for 2025.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You may choose a Self Only enrollment even though you have a family, however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP. 

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 11, 2024 through midnight EST December 9, 2024 Open Season.  Coverage is effective January 1, 2025.

During future annual open seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these open season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;
• a previously ineligible employee who transferred to a covered position;
• a survivor annuitant if not already covered under FEDVIP;
• an employee returning to service following a break in service of at least 31 days; or
• a TRICARE-eligible individual.

Qualifying Life Event
A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an open season.  

The following chart lists the QLEs and the enrollment actions you may take:

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non-pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium and you elect to enroll.  

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event. There are two exceptions:  

• There is no time limit for a change based on moving from a regional plan’s service area; and 
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of a loss of dental or vision insurance. You must make the change no later than 60 days after the event. 

Enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives the enrollment or change. BENEFEDS will send you confirmation of your new coverage effective date.  

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed. That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next open season, unless you experience a QLE that allows such a change or cancellation.  

VA Exception for Cancellation 

Generally, you may cancel your enrollment only during the annual open season. However, if you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may change your enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or vision eligibility documentation must be submitted to OPM via the BENEFEDS mailbox (benefedsportal@opm.gov) within 60 days of notification to support the FEDVIP enrollment change or cancellation. 

Your cancellation is effective at the end of the day before the date OPM sets as the open season effective date. An eligible family member’s coverage also ends upon the effective date of the cancellation. 

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may not change or cancel your FEDVIP enrollment until the next open season. 

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post- tax basis by contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680. 

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

• no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
• as a Retired Reservist you begin active duty;
• as sponsor or primary enrollee leaves active duty;
• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• cancel the enrollment during open season;
• a Retired Reservist begins active duty; or
• the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or
• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage.  The following are also NOT available under the FEDVIP plans:

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account. Please note that insurance premiums are not eligible expenses for either type of FSA.   

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans (https://www.irs.gov/forms-pubs/about-publication-969) for additional information about carryover and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX HCFSA FSAFEDS account and you have not exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over a set maximum amount of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st. You must also actively re-enroll in a health care or limited expense account during the next open season to be carryover eligible. Your re-enrollment must meet the minimum contribution amount for the plan year. If you do not re-enroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over. 

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time permitted. This is known as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect.

Current FSAFEDS participants must re-enroll to participate in the program next year. See 
https://www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058. Note: FSAFEDS is not open to retired employees or to TRICARE eligible individuals. 

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB/PSHB and/or FEDVIP plans.

We will send you an identification (ID) card when you enroll within 15 days of your effective date.  You must show it whenever you receive services from a plan provider.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (877) 434-2336 or write us at G.E.H.A Enrollment, P.O. Box 21262, Eagan, MN 55121.

Existing members who were previously issued an ID card will not receive new ID cards unless otherwise requested or G.E.H.A receives a name change/correction or change in plan from BENEFEDS.

You may also print a temporary ID card after signing in to your member account on our website: www.geha.com.

It is important to bring your FEDVIP and FEHB/PSHB identification cards to every dental appointment because most FEHB/PSHB plans offer some level of dental benefits separate from your FEDVIP coverage.  Presenting both identification cards can ensure that you receive the maximum allowable benefit under both Programs.

Each covered person has the right to choose any licensed dental practitioner.  We list plan providers in the provider directory, which we update periodically.  The list is on our website at www.geha.com/Find-Care. You may also call us at (877) 434-2336 for help in locating a preferred provider.

Care that you receive from an in-network preferred provider (PPO).  To obtain care, simply select a provider and make an appointment.  Referrals to a specialist are not necessary.  The plan does not require you to see a primary care provider before seeing a specialist.  Information on preferred dentists can be obtained free of charge.  Visit our website at www.geha.com/Find-Care or call (877) 434-2336.

The list of preferred providers is subject to change.  Before you receive care, it is your responsibility to verify with the preferred provider that the provider currently participates at the office location where you will be seen.

G.E.H.A does not guarantee that preferred providers are available for all specialties, are available in all areas or that the Connection Dental Maximum Allowable Charge is less than what you might obtain from non-preferred providers.

Care that you receive from a provider that does not participate in our network of providers.  G.E.H.A reimburses for covered dental care from any covered provider. Non-PPO providers have no agreement to limit what they will bill you.

The plan does not require a pre-determination of benefits.  G.E.H.A will respond to a request to pre-determine services with an estimate of covered service, which is non-binding and not a guarantee of payment since future changes such as changes in your enrollment or eligibility under the plan may affect benefits.  We encourage you to ask your provider to request a pre-determination for any extensive treatment.  By obtaining a pre-determination, you and your dental provider will have an estimate before treatment begins of what will be covered and how it will be paid.  This information can be valuable to you in making an informed decision on how to proceed with treatment and can help protect you from unexpected out-of-pocket costs should the treatment plan not be covered.

Pre-determinations are valid through the calendar year in which they are prepared, or 12 months, subject to eligibility and plan limitations.

To obtain a pre-determination, the dentist should submit a completed dental pre-treatment estimate claim form that itemizes the proposed procedure codes, charge for each procedure along with a pre-treatment plan, radiographic image and any other diagnostic materials.

When you visit a provider who participates with both your FEHB/PSHB plan and your FEDVIP plan, the FEHB/PSHB plan will pay benefits first. In these cases, the FEDVIP plan's allowable will be the lesser of: (a) the negotiated allowable charge between the FEDVIP plan and the provider; or (b) the negotiated allowable charge between the FEHB/PSHB plan and the provider.

You are responsible for the difference between the total FEHB/PSHB and FEDVIP payments and the allowable as defined above.  

We are responsible for facilitating the process with the primary FEHB/PSHB first payor. 

It is important to bring your FEDVIP and FEHB/PSHB identification cards to every dental appointment because most FEHB/PSHB plans offer some level of dental benefits separate from your FEDVIP coverage.  Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

Example: Provider is in-network with both FEDVIP plan and FEHB/PSHB plan. The provider can collect up to the lowest allowable as payment in full.

FEDVIP G.E.H.A high option member with FEHB/PSHB coverage FEHB/PSHB plan is always primary payor G.E.H.A Connection Dental Federal high option plan is secondary
Charges by an In-Network Provider
Extraction of tooth: $150.00
Primary FEHB/PSHB allowable: $123.00
Primary FEHB/PSHB payment (estimated): $21.00
FEDVIP allowable: $131.00
FEDVIP payment: $123.00 X 80% = $98.40
Total of primary payment and FEDVIP Payments: $21.00 + $98.40 = $119.40
Patient responsibility: $123.00 - $119.40 = $3.60

Example: Provider is out-of-network with both FEDVIP plan and FEHB/PSHB plan. The provider can collect up to their billed charge.

FEDVIP G.E.H.A high option member with FEHB/PSHB coverage. FEHB/PSHB plan is always primary payor. G.E.H.A Connection Dental Federal high option plan is secondary
Charges by Out-of-Network Provider
Extraction of tooth: $150.00
Primary FEHB/PSHB payment (estimated): $21.00
FEDVIP allowable: $131.00
FEDVIP payment: $131.00 X 80% = $104.80
Total of primary payment and FEDVIP payments: $21.00 + $104.80 = $125.80
Balance which is patient responsibility: $150.00 - $125.80 = $24.20

We determine which non-FEHB/non-PSHB coverage is primary according to National Association of Insurance Commissioners’ (NAIC) guidelines. When you visit a provider who participates with both your FEHB/PSHB plan and your FEDVIP plan, refer to the “FEHB/PSHB First Payor” section. We will coordinate benefit payments with the payment of benefits under other group health benefits coverage you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault.

For example, if your spouse has other group dental coverage on the family in addition to this plan and your FEHB/PSHB plan, your spouse’s plan would pay first for your spouse’s charges, your FEHB/PSHB plan would pay second and this plan would pay third.

We may request that you verify/identify your health insurance plan(s) annually or at the time of service.  You may call or mail other coverage information or report it online at www.geha.com/DentalCOB.

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor.  We will consider any benefits payable by your FEHB/PSHB medical plan before we calculate benefits payable by us. In addition to benefits payable by your FEHB/PSHB medical plan, if you or your covered dependents have other dental coverage, you must tell G.E.H.A.  When we are secondary or tertiary (third) payor, our payment will be the lesser of the following:

• G.E.H.A's benefits; or
• The remaining balance which when added to the other carrier(s’) payment will not exceed the dentist billed amount or lowest negotiated rate.

There is no change in benefit limits or maximums when we are the secondary payor. 

Example: Provider is in-network with both FEDVIP plan and other plan. The provider can collect up to the lowest allowable as payment in full.

FEDVIP G.E.H.A high option member with other plan coverage
G.E.H.A Connection Dental Federal high option plan is secondary
Charges by In-Network Provider
Extraction of tooth: $150.00
Primary allowable: $123.00
Primary payment: $21.00
FEDVIP allowable: $131.00
FEDVIP payment: $123.00 X 80% = $98.40
Total of primary payment and FEDVIP payments: $21.00 + $98.40 = $119.40
Patient responsibility: $123.00 - $119.40 = $3.60

Example: Provider is out-of-network with both FEDVIP plan and other plan. The provider can collect up to their billed charge.

FEDVIP G.E.H.A high option member with other plan coverage
G.E.H.A Connection Dental Federal high option plan is secondary
Charges by Out-of-Network Provider
Extraction of tooth: $150.00
Primary payment: $21.00
FEDVIP allowable: $131.00
FEDVIP payment: $131.00 X 80% = $104.80
Total of primary payment and FEDVIP payments: $21.00 + $104.80 = $125.80
Balance which is patient responsibility: $150.00 - $125.80 = $24.20

Please see Section 4, Your Cost For Covered Services, for more information about how we pay claims. If your primary payor requires a pre-determination or requires that you use designated facilities for benefits to be approved, it is your responsibility to comply with these requirements. In addition, you must file the claim with your primary payor within the required time period. If you fail to comply with any of these requirements and the primary payor denies benefits, we will pay secondary benefits based on an estimate of what the primary carrier would have paid if you had followed their requirements.

Your rates are determined based on where you live.  This is called a rating area.  If you move, you must update your address through BENEFEDS at www.BENEFEDS.gov or by phone at (877) 888-3337.  Your rates might change because of the move.

If you live in an area that does not have adequate access to in-network general dentists as determined by your 5-digit ZIP code and you receive covered services from an out-of-network provider, we will base our plan allowance on the 75^th percentile of standard healthcare prevailing fees.  You are responsible for any difference between the amount billed and our payment.  For a list of our limited access areas, call (877) 434-2336.

In some cases, you and your dental practitioner have a choice of treatment options.  In an effort to keep your dental premiums affordable and assure you have coverage for the most common types of dental treatment, the dental plan limits benefits to the maximum allowable charge for the least costly covered service that accomplishes a result that meets accepted standards of professional dental care as determined by us.

If you or your dental practitioner should choose a more costly treatment or service, we will limit benefits payable to the benefit that would have been payable if the least costly covered service had been provided.  This is called the alternate benefit.  Any difference between the alternate benefit and the charge actually incurred is your responsibility, including any applicable coinsurance.  In Section 5, services listed with an asterisk (*) often have the choice of a lower cost treatment.  If you or your dental provider should choose this treatment or service, we will allow the lower cost alternative benefit unless evidence is submitted with the bill to explain why the less expensive treatment could not be done.

We decide the alternative benefit for covered services when we receive the claim.  To avoid incurring expenses we will not cover, we encourage you to request a pre-determination of benefits before treatment begins.

Some services require additional information in order to determine if the services are covered or subject to an alternative benefit.  The tooth number is required with claim submission to avoid claim processing delays.  Radiographic images are required for crowns, periodontal procedures, inlays/onlays, anterior and multiple restorations, crown build-ups and implants.  The complete treatment plan is also needed for implants.  Charting is required for periodontal procedures.  The date (month and year) of prior placement is required for replacement dentures, partials, crowns and bridges.  The degree and classification of malocclusion is required for orthodontics.

Crown – A pre-operative bitewing and periapical radiographs are required to determine if services meet benefit guidelines for coverage. Date (month and year) of any prior crown is required, if replacement. 

Implant – Radiographic images of full arch or panoramic radiographic image are required for implants along with the treatment plan for replacing all missing teeth and teeth that require extraction. Date (month and year) of any prior prosthesis replacing tooth/teeth to be replaced with implant(s).

Orthodontics – The degree and classification of malocclusion is required for orthodontics as follows:

• Classification of malocclusion (this means Class I, II, III), including narrative
• Degree of overjet, in mm
• Degree of overbite, in mm
• Anterior crowding discrepancy in mm
• Anterior spacing discrepancy in mm
• Description, if any, of cross bite
• Total number of months required for treatment
• Treatment objective
• Cephalometric image or tracing, if available
• Panoramic radiographic image
• Diagnostic photos

Periodontal – Full mouth or panoramic radiographs including current bitewing radiographs, periodontal charting, provider narrative and any additional diagnostic information necessary to determine if services meet benefit guidelines for coverage.

By submitting this information with your claim, you may avoid claim processing delays.

A copayment is a fixed amount of money you pay to the provider when you receive services.

G.E.H.A Connection Dental Federal^®High Option – no copay.

G.E.H.A Connection Dental Federal^®Standard Option – no copay.

A deductible is a fixed amount of expenses you must incur for certain covered services before we will pay for covered services. Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.

There is no calendar year deductible for High Option or Standard in-network. Standard Option out-of-network Services under Class A, B and C are subject to a combined $75 Deductible per person, per calendar year. 

Coinsurance is the percentage of our allowance that you must pay for your care.  We will base this percentage on either the billed charge or the plan allowance, whichever is less.

For High Option your coinsurance is as follows:

• Class A – nothing
• Class B – 20%
• Class C – 50%
• Class D – 30%

For Standard Option your coinsurance is as follows:

      In-Network                 

• Class A – nothing        
• Class B – 45%                   
• Class C – 65%               
• Class D – 50%                

      Out-of-Network

• Class A – 25%        
• Class B – 50%                   
• Class C – 70%               
• Class D – 50% 

Note: If your provider routinely waives (does not require you to pay) your coinsurance, the provider is misstating the fee and may be violating the law.  In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.  For example, if your dentist ordinarily charges $100 for a service but routinely waives your 50 percent coinsurance, the actual charge is $50.  We will pay $25 (50 percent of the actual charge of $50).

Once you reach this amount, you are responsible for all charges.  For High Option, there is an unlimited annual benefit maximum per person for combined Class A, Class B and Class C covered services.  For Standard Option, there is an annual benefit maximum per person of $2,500 for in-network services and $2,000 for out-of-network services for combined Class A, Class B and Class C covered services.  Once the annual benefit maximum has been met, no additional benefits will be paid for Class A, Class B or Class C covered services for that person for that calendar year.

The lifetime benefit maximum applies to orthodontic (Class D) covered services only.  Once you reach this amount, you are responsible for all charges.  This plan has a lifetime benefit maximum of $3,500 per person for High Option and $2,500 for in-network Class D services, $1,500 for out-of-network Class D services for Standard Option.

Note: The lifetime benefit maximum applies even if you do not remain continuously enrolled.  Any amount applied to the lifetime benefit maximum while previously covered under this plan will apply toward your lifetime benefit maximum when you re-enroll with this plan.

And, if you change from High Option to Standard Option (or vice versa) in the plan during the year or during open season, we will apply the amount previously applied to the lifetime benefit maximum from your old option to the lifetime benefit maximum of your new option.

In-Network services are services provided by an in-network preferred provider, also referred to as a PPO provider.  Often, the provider’s bill is more than a fee-for-service plan’s allowance.  Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.  In-Network providers agree to limit what they will bill you.  Because of that, when you use a preferred provider, your share of covered charges consists only of your coinsurance or any amount remaining after the annual maximum is met.  Here is an example of how using a preferred provider can save you money:  You see a PPO dental practitioner who charges $120 for a Class B restorative service and our maximum allowable is $100.  If you have not met your annual maximum, you are only responsible for your coinsurance.  That is, with High Option, you pay just 20 percent of our $100 allowance ($20).  Because of the agreement, your PPO dental practitioner will not bill you for the $20 difference between our allowance and the bill.

Out-of-Network services are services provided by a provider that does not participate in our network of providers, also referred to as non-PPO providers.  Non-PPO providers have no agreement to limit what they will bill you.  When you use a Non-PPO provider, you will pay your coinsurance, plus any difference between our allowance and charges on the bill.  Here is an example: You see a non-PPO dental practitioner who charges $120 and our maximum allowance is $100.  Because you have not met your annual maximum, you are responsible for your coinsurance, so with High Option you pay 20 percent of our $100 allowance ($20).  Plus, because there is no agreement between the non-PPO provider and us, your dental practitioner can also bill you for the $20 difference between our allowance and the bill for a total of $40.

The plan allowance is the amount we allow for a specific procedure.  When you use a participating provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment.  The plan allowance may vary upon geographic location and/or a participating providers contracted fee schedule.  When you use an out-of-network provider, you are responsible for the difference between our payment and the billed amount.

We will make diligent efforts to recover benefit payments we made in error but in good faith.  We may reduce subsequent benefit payments to offset overpayments.  G.E.H.A may collect the overpayment from the member if G.E.H.A has exhausted every effort to recover an overpayment made to a provider.  Federal Laws supersede State Laws regarding our right to recovery of overpayments.

If G.E.H.A pays benefits for an illness or injury for which you or your dependent are later compensated or reimbursed from another source, you must refund G.E.H.A from any recovery you or your dependent obtain.  All G.E.H.A benefit payments in these circumstances are conditional, and remain subject to our contractual benefit limitations, exclusions and maximums.

In-progress treatment for dependents of retiring active-duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2025 plan year, regardless of any current plan exclusion for care initiated prior to the enrollee’s effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2025 plan year such as crowns and implants.

Oral evaluations (D0120 Periodic oral evaluation - established patient, D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver, D0150 Comprehensive oral evaluation - new or established patient, D0180 Comprehensive periodontal evaluation - new or established patient) are limited to a maximum of two times per Calendar Year.

D0120 Periodic oral evaluation - established patient

D0140 Limited oral evaluation – problem focused - One D0140 Limited oral evaluation - problem focused will be allowed per patient per dentist in a 12 consecutive month period. A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.

D0140 Limited oral evaluation - problem focused - When billed with D9995 Teledentistry – synchronous; real-time encounter and D9996 Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review. When you use the service at www.Teledentistry.com/geha for after hours emergency care. One D0140 Limited oral evaluation - problem focused will be allowed per patient in a 12 consecutive month period.

D0150 Comprehensive oral evaluation - new or established patient

D0180 Comprehensive periodontal evaluation - new or established patient

D0210 Intraoral – comprehensive series of radiographic images – Full mouth radiographic images and panoramic radiographic image are limited to a combined maximum of once every 3 Calendar Years.

D0230 Intraoral – periapical each additional radiographic image

Intraoral occlusal, extra-oral 2D and extra-oral posterior x-rays are limited to a combined maximum of 4 per Calendar Year.

D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector

D0251 Extra-oral posterior dental radiographic image

Bitewing radiographic images are limited to twice per Calendar Year for children 22 and younger and once per Calendar Year for adults 23 and older. This includes D0270 Bitewing - single radiographic image, D0272 Bitewings - two radiographic images, D0273 Bitewings - three radiographic images, D0274 Bitewings - four radiographic images and D0277 Vertical bitewings - 7 to 8 radiographic images.

D0270 Bitewing – single radiographic image

D0272 Bitewings - two radiographic images

D0273 Bitewings - three radiographic images

D0274 Bitewings - four radiographic images

D0277 Vertical bitewings - 7 to 8 radiographic images

D0330 Panoramic radiographic image – Full mouth radiographic images and panoramic radiographic image are limited to a combined maximum of once every 3 Calendar Years.

D1110 Prophylaxis – adult – If enrolled in Standard Option, limited to twice per calendar year. If enrolled in High Option, limited to three per calendar year. 

D1120 Prophylaxis – child – Limited to twice per Calendar Year.

Topical application of fluoride is limited to Covered Persons under age 22 twice per Calendar Year.

D1208 Topical application of fluoride – excluding varnish

Sealants are limited to Covered Persons under 18 years of age on unrestored permanent molars only and are limited to one sealant per tooth every 3 Calendar Years, which includes D1351 Sealant - per tooth and D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth.

D1353 Sealant repair - per tooth - Limited to once per tooth, per lifetime.

D1354 Application of caries arresting medicament – per tooth – Per lifetime, limited to children under 9 years of age.

 Space maintainers are limited to initial appliance, no more than one per tooth, which includes D1510 Space maintainer - fixed, unilateral – per quadrant, D1516 Space maintainer - fixed - bilateral, maxillary, D1517 Space maintainer - fixed - bilateral, mandibular, D1520 Space maintainer - removable, unilateral - per quadrant, D1526 Space maintainer - removable - bilateral, maxillary, D1527 Space maintainer - removable - bilateral, mandibular and D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant, for non-orthodontic treatment of prematurely lost teeth in children under age 19.

D1510 Space maintainer – fixed, unilateral – per quadrant

D1516 Space maintainer – fixed – bilateral, maxillary

D1517 Space maintainer – fixed – bilateral, mandibular

D1520 Space maintainer - removable, unilateral - per quadrant

D1526 Space maintainer – removable – bilateral, maxillary

D1527 Space maintainer – removable – bilateral, mandibular

Current Dental Terminology © American Dental Association

D1551 Re-cement or re-bond bilateral space maintainer - maxillary – Limited twice per Calendar Year combined with D1552 Re-cement or re-bond bilateral space maintainer - mandibular and D1553 Re-cement or re-bond unilateral space maintainer - per quadrant.

D1552 Re-cement or re-bond bilateral space maintainer – mandibular – Limited twice per Calendar Year combined with D1551 Re-cement or re-bond bilateral space maintainer - maxillary and D1553 Re-cement or re-bond unilateral space maintainer - per quadrant.

D1553 Re-cement or re-bond unilateral space maintainer – per quadrant – Limited twice per Calendar Year combined with D1551 Re-cement or re-bond bilateral space maintainer - maxillary and D1552 Re-cement or re-bond bilateral space maintainer - mandibular.

D1575 Distal shoe space maintainer – fixed, unilateral – per quadrant

D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use - Limited to once per lifetime.

D9110 Palliative treatment of dental pain - per visit 

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician - Limited to once per patient, per provider (dentist) per lifetime.

D9311 Consultation with a medical health care professional - Limited to once per Covered Person per lifetime.

D9440 Office visit - after regularly scheduled hours

Not covered:

• Plaque control programs
• Oral hygiene instruction
• Dietary instructions
• Over-the-counter dental products, such as teeth whiteners, toothpaste, dental floss
• Any exclusions or limitations listed under Section 7 of this plan document
• Charges for missed appointments
• Filling out paperwork
• Submitting claim forms
• Sterilizing instruments

Current Dental Terminology © American Dental Association

Restorations are limited to one restoration per tooth surface every 2 Calendar Years. 

D2140 Amalgam – one surface, primary or permanent

D2150 Amalgam – two surfaces, primary or permanent

D2160 Amalgam – three surfaces, primary or permanent

D2161 Amalgam – four or more surfaces, primary or permanent

D2330 Resin-based composite – one surface, anterior

D2331 Resin-based composite – two surfaces, anterior

D2332 Resin-based composite – three surfaces, anterior

D2335 Resin-based composite – four or more surfaces (anterior)

D2390 Resin-based composite crown, anterior - Limited to anterior primary teeth only, once per tooth, per lifetime.

*D2610 Inlay - porcelain/ceramic - one surface

*D2620 Inlay - porcelain/ceramic - two surfaces 

*D2630 Inlay - porcelain/ceramic - three or more surfaces

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration – Limited to once per 6 month period if more than 12-months from initial placement.

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core - Limited to once per tooth, per lifetime.

D2920 Re-cement or re-bond crown – Limited to once per 6 month period if more than 12-months from initial placement.

D2921 Reattachment of tooth fragment, incisal edge or cusp - Limited to once per tooth, per lifetime.

D2929 Prefabricated porcelain/ceramic crown - primary tooth - Limited to one per patient, per tooth, per lifetime for Covered Persons under 15 years of age.

D2930 Prefabricated stainless steel crown – primary tooth – Limited to one per patient, per tooth, per lifetime for Covered Persons under 15 years of age.

D2931 Prefabricated stainless steel crown – permanent tooth – Limited to one per patient, per tooth, per lifetime for Covered Persons under 15 years of age.

D2951 Pin retention – per tooth, in addition to restoration

D2991 Application of hydroxyapatite regeneration medicament - per tooth - Limited to 2 per calendar year per tooth

Not covered:

• Restorations, including veneers, which are placed for cosmetic purposes only 
• Gold foil restorations
• Any exclusions or limitations listed under Section 7 of this plan document

D3110 Pulp cap – direct (excluding final restoration) - Coverage determined by report. 

D3120 Pulp cap – indirect (excluding final restoration) - Coverage determined by report. 

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament –Therapeutic pulpotomy is limited to once per tooth per lifetime.

D3221 Pulpal debridement, primary and permanent teeth - Limited to once per tooth, per lifetime.

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development - Limited to once per tooth, per lifetime.

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) – Limited to primary incisor teeth for children up to age 6 and cuspids up to age 11 and is limited to once per tooth per lifetime.

Current Dental Terminology © American Dental Association

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) – Limited to primary molars for children up to age 11 and is limited to once per tooth per lifetime.

D3921 Decoronation or submergence of an erupted tooth

Periodontal scaling and root planing are limited to once per quadrant every 2 Calendar Years and are not covered if done within 24 months of periodontal surgical procedures in the same quadrant.

D4341 Periodontal scaling and root planing – four or more teeth per quadrant

D4342 Periodontal scaling and root planing – one to three teeth per quadrant

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation – Limited to a maximum of once every 2 Calendar Years. This service replaces a routine prophylaxis for the calendar year in which it was performed.

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth - Service is only covered for residual periodontal disease with inflammation and the service is necessary to treat specific sites that are unresponsive to prior active periodontal treatment. Limited to once per tooth, per lifetime. Coverage determined by report.

D4910 Periodontal maintenance – Periodontal maintenance is only covered when performed following active periodontal treatment. Routine prophylaxis and periodontal maintenance are limited to a combined total of four per Calendar Year.

D7921 Collection and application of autologous blood concentrate product – Coverage determined by report.

D5410 Adjust complete denture – maxillary

D5411 Adjust complete denture – mandibular

D5421 Adjust partial denture – maxillary

D5422 Adjust partial denture – mandibular

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

D5520 Replace missing or broken teeth - complete denture - per tooth

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

D5630 Repair or replace broken retentive clasping materials – per tooth

D5640 Replace missing or broken teeth – partial denture – per tooth

D5650 Add tooth to existing partial denture – per tooth

D5660 Add clasp to existing partial denture – per tooth

Replacement of all teeth and acrylic on cast metal framework is limited to once every five Calendar Years.

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 

D5671 Replace all teeth and acrylic on cast metal framework (mandibular)

Tissue conditioning, rebase and reline of dentures is limited to a maximum of once every 3 Calendar Years after 6 months of initial placement.

D5710 Rebase complete maxillary denture

D5711 Rebase complete mandibular denture

D5720 Rebase maxillary partial denture

D5721 Rebase mandibular partial denture

Current Dental Terminology © American Dental Association

D5725 Rebase hybrid prosthesis

D5730 Reline complete maxillary denture (direct)

D5731 Reline complete mandibular denture (direct)

D5740 Reline maxillary partial denture (direct)

D5741 Reline mandibular partial denture (direct)

D5750 Reline complete maxillary denture (indirect)

D5751 Reline complete mandibular denture (indirect)

D5760 Reline maxillary partial denture (indirect)

D5761 Reline mandibular partial denture (indirect)

D5765 Soft liner for complete or partial removable denture – indirect

D5850 Tissue conditioning, maxillary – Not covered if done the same day as delivery of dentures, reline or rebase.

D5851 Tissue conditioning, mandibular – Not covered if done the same day as delivery of dentures, reline or rebase.

D6930 Re-cement or re-bond fixed partial denture – Recement of fixed partial denture, or bridge is limited to one per Calendar Year, after 6 months of initial placement.

D6980 Fixed partial denture repair necessitated by restorative material failure – Coverage determined by report. 

D7111 Extraction, coronal remnants - primary tooth

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

Removal of impacted tooth – Removal of impacted third molars in Covered Persons is not covered unless specific documentation is provided that substantiates the need for removal and is approved by us.

D7220 Removal of impacted tooth – soft tissue

D7230 Removal of impacted tooth – partially bony

D7240 Removal of impacted tooth – completely bony

*D7241 Removal of impacted tooth – completely bony, with unusual surgical complications

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7270 Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth

D7280 Exposure of an unerupted tooth - Limited to one per tooth, per lifetime.

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7471 Removal of lateral exostosis (maxilla or mandible)

D7510 Incision and drainage of abscess – intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

D7971 Excision of pericoronal gingiva

*D7999 Unspecified oral surgery procedure, by report - Coverage determined by report. The plan allowance will be determined upon review of the report.

Current Dental Terminology © American Dental Association

D0160 Detailed and extensive oral evaluation – problem focused, by report – Detailed and extensive oral evaluations are limited to once per covered person per dentist, per lifetime.

Crowns, inlays, onlays and posts and cores are payable only when required for restorative purposes and necessary due to extensive decay or significant tooth fracture and evidence is presented showing the tooth cannot be adequately restored with an amalgam or composite restoration.

*D2520 Inlay - metallic - two surfaces

*D2530 Inlay - metallic - three or more surfaces

*D2542 Onlay – metallic – two surfaces

*D2543 Onlay – metallic – three surfaces

*D2544 Onlay – metallic – four or more surfaces

*D2642 Onlay – porcelain/ceramic – two surfaces

*D2643 Onlay – porcelain/ceramic – three surfaces

*D2644 Onlay – porcelain/ceramic – four or more surfaces

*D2662 Onlay – resin-based composite – two surfaces

*D2663 Onlay – resin-based composite – three surfaces

*D2664 Onlay – resin-based composite – four or more surfaces

*D2710 Crown – resin-based composite (indirect)

*D2712 Crown – 3/4 resin-based composite (indirect)

*D2720 Crown – resin with high noble metal

*D2721 Crown – resin with predominantly base metal

*D2722 Crown – resin with noble metal

*D2740 Crown – porcelain/ceramic

*D2750 Crown – porcelain fused to high noble metal

*D2751 Crown - porcelain fused to predominantly base metal

*D2752 Crown – porcelain fused to noble metal

*D2753 Crown – porcelain fused to titanium and titanium alloys

*D2780 Crown – 3/4 cast high noble metal

D2781 Crown - 3/4 cast predominantly base metal 

*D2782 Crown – 3/4 cast noble metal

*D2783 Crown – 3/4 porcelain/ceramic - For posterior teeth only

*D2790 Crown – full cast high noble metal

D2791 Crown - full cast predominantly base metal

*D2792 Crown – full cast noble metal

Current Dental Terminology © American Dental Association

*D2794 Crown – titanium and titanium alloys

D2950 Core buildup, including any pins when required – Core buildups are covered only when there is evidence presented showing insufficient retention for a crown.

Posts are only covered when provided as part of a buildup for a crown. When performed as an independent procedure, the placement of a post is not covered.

*D2952 Post and core in addition to crown, indirectly fabricated

*D2953 Each additional indirectly fabricated post - same tooth

D2954 Prefabricated post and core in addition to crown

*D2957 Each additional prefabricated post – same tooth

D2980 Crown repair necessitated by restorative material failure – Coverage determined by report.  

D2981 Inlay repair necessitated by restorative material failure - Coverage determined by report.

D2982 Onlay repair necessitated by restorative material failure - Coverage determined by report.

D2983 Veneer repair necessitated by restorative material failure - Coverage determined by report.

Not covered:

• Gold foil restorations
• Protective restoration 
• Restorations for cosmetic purposes only
• Composite resin inlays
• Any exclusions or limitations listed under Section 7 of this plan document

D3310 Endodontic therapy, anterior tooth (excluding final restoration) - Limited to once per tooth, per lifetime.

D3320 Endodontic therapy, premolar tooth (excluding final restoration) - Limited to once per tooth, per lifetime.

D3330 Endodontic therapy, molar tooth (excluding final restoration) - Limited to once per tooth, per lifetime.

Retreatment of root canal is covered only after 12 months from the prior root canal therapy.

D3346 Retreatment of previous root canal therapy – anterior

D3347 Retreatment of previous root canal therapy – premolar

D3348 Retreatment of previous root canal therapy – molar

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) - Limited to once per tooth, per lifetime.

D3352 Apexification/recalcification – interim medication replacement - Limited to once per tooth, per lifetime.

D3353 Apexification/recalcification – final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) - Limited to once per tooth, per lifetime.

D3355 Pulpal regeneration – initial visit - Coverage determined by report. Limited to once per tooth, per lifetime.

D3356 Pulpal regeneration – interim medication replacement - Coverage determined by report. Limited to once per tooth, per lifetime.

D3357 Pulpal regeneration – completion of treatment – Coverage determined by report. Limited to once per tooth, per lifetime.

D3410 Apicoectomy - anterior - Limited to once per tooth, per lifetime.

D3421 Apicoectomy - premolar (first root) - Limited to once per tooth, per lifetime.

D3425 Apicoectomy - molar (first root) - Limited to once per tooth, per lifetime.

D3426 Apicoectomy (each additional root) - Limited to 2 per tooth on molar teeth per lifetime, and once per tooth on premolar and anterior teeth per lifetime.

Current Dental Terminology © American Dental Association

D3450 Root amputation – per root

D3471 Surgical repair of root resorption - anterior

D3472 Surgical repair of root resorption - premolar

D3473 Surgical repair of root resorption - molar

D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior

D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar

D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption - molar

D3920 Hemisection (including any root removal), not including root canal therapy

Gingivectomy, gingivoplasty, gingival flap procedure, and osseous surgery are limited to once per quadrant every 2 Calendar Years and are not covered when treating implant and edentulous areas.

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth - Limited to once per tooth every 2 Calendar Years with restorative procedure.

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant

D4249 Clinical crown lengthening – hard tissue - Limited to once per tooth, per lifetime.

D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant 

D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

D4270 Pedicle soft tissue graft procedure – Tissue graft procedures are not covered when treating implants or in edentulous areas. Grafts on additional contiguous teeth are payable as secondary procedures. Charges for guided tissue regeneration and use of collagen are considered components of this procedure.

D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft – Tissue graft procedures are not covered when treating implants or in edentulous areas.

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft – Tissue graft procedures are not covered when treating implants or in edentulous areas.

D4276 Combined connective tissue and pedicle graft, per tooth - Grafts on additional contiguous teeth payable as secondary procedures.

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft – Tissue graft procedures are not covered when treating implants or in edentulous areas.

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site - Tissue graft procedures are not covered when treating implants or in edentulous areas.

D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site - Tissue graft procedures are not covered when treating implants or in edentulous areas.

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site - Tissue graft procedures are not covered when treating implants or in edentulous areas.

Current Dental Terminology © American Dental Association

D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit – Limited to once per lifetime.

D4999 Unspecified periodontal procedure, by report - Coverage determined by report. The plan allowance will be determined upon review of the report.

The replacement of a prior prosthodontic device will be considered a covered service only if at least one of the following conditions is met:

• The replacement appliance replaces an existing appliance that is at least 5 years old and cannot be made serviceable.
• The replacement appliance is required as the result of accidental bodily injury that occurs after the date the person became a covered person and the appliance cannot be made serviceable.

D5110 Complete denture – maxillary

D5120 Complete denture – mandibular

D5130 Immediate denture – maxillary

D5140 Immediate denture – mandibular

D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5221 Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth)

D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth)

D5223 Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5224 Immediate mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5225 Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

D5226 Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth)

D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth)

D5282 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

D5284 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per quadrant

D5286 Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth) – per quadrant

D5876 Add metal substructure to acrylic full denture (per arch) - Coverage determined by report. 

D6205 Pontic – indirect resin based composite – Not to be used as a temporary or provisional prosthesis.

*D6210 Pontic – cast high noble metal

*D6211 Pontic - cast predominantly base metal

*D6212 Pontic – cast noble metal

*D6214 Pontic – titanium and titanium alloys

*D6240 Pontic – porcelain fused to high noble metal

Current Dental Terminology © American Dental Association

*D6241 Pontic - porcelain fused to predominantly base metal

*D6242 Pontic – porcelain fused to noble metal

*D6243 Pontic – porcelain fused to titanium and titanium alloys

*D6245 Pontic – porcelain/ceramic

*D6545 Retainer – cast metal for resin bonded fixed prosthesis

*D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis

*D6549 Retainer – resin bonded fixed prosthesis

*D6604 Retainer inlay - cast predominantly base metal, two surfaces

*D6605 Retainer inlay - cast predominantly base metal, three or more surfaces

*D6613 Retainer onlay - cast predominantly base metal, three or more surfaces

*D6740 Retainer crown - porcelain/ceramic

*D6750 Retainer crown - porcelain fused to high noble metal

*D6751 Retainer crown - porcelain fused to predominantly base metal

*D6752 Retainer crown - porcelain fused to noble metal

*D6753 Retainer crown – porcelain fused to titanium and titanium alloys

*D6780 Retainer crown - 3/4 cast high noble metal

*D6781 Retainer crown - 3/4 cast predominantly base metal

*D6782 Retainer crown - 3/4 cast noble metal

*D6783 Retainer crown - 3/4 porcelain/ceramic

*D6784 Retainer crown ¾ – titanium and titanium alloys

*D6790 Retainer crown - full cast high noble metal

*D6791 Retainer crown - full cast predominantly base metal

*D6792 Retainer crown - full cast noble metal

*D6794 Retainer crown - titanium and titanium alloys

Implant Services – The following implant procedure codes may be allowed under the implant benefit. We will limit payment on covered implant(s) - including abutment, implant, crown, implant-supported appliances such as partial denture (bridge), pontic, full denture and other implant procedures to a calendar year maximum of $2,500 or $2,000 for Standard Option if out-of-network. Replacement implant services are covered only 5 years after initial placement of existing implant or appliance to replace missing teeth unless required as a result of an accidental bodily injury and satisfactory evidence is presented showing the implant services could not be made serviceable.

*D6010 Surgical placement of implant body: endosteal implant

*D6013 Surgical placement of mini implant

*D6040 Surgical placement: eposteal implant

*D6050 Surgical placement: transosteal implant

*D6055 Connecting bar - implant supported or abutment supported

*D6056 Prefabricated abutment – includes modification and placement

*D6057 Custom fabricated abutment – includes placement

*D6058 Abutment supported porcelain/ceramic crown

*D6059 Abutment supported porcelain fused to metal crown (high noble metal)

*D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)

*D6061 Abutment supported porcelain fused to metal crown (noble metal)

*D6062 Abutment supported cast metal crown (high noble metal)

Current Dental Terminology © American Dental Association

*D6063 Abutment supported cast metal crown (predominantly base metal)

*D6064 Abutment supported cast metal crown (noble metal)

*D6065 Implant supported porcelain/ceramic crown

*D6066 Implant supported crown – porcelain fused to high noble alloys 

*D6067 Implant supported crown – high noble alloys

*D6068 Abutment supported retainer for porcelain/ceramic FPD

*D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

*D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)

*D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)

*D6072 Abutment supported retainer for cast metal FPD (high noble metal)

*D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)

*D6074 Abutment supported retainer for cast metal FPD (noble metal)

*D6075 Implant supported retainer for ceramic FPD

*D6076 Implant supported retainer for FPD – porcelain fused to high noble alloys

*D6077 Implant supported retainer for metal FPD – high noble alloys

D6080 Implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments

D6081 Scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure – Limited to a maximum of once every 2 Calendar Years. Coverage determined by report. 

*D6082 Implant supported crown - porcelain fused to predominantly base alloys

*D6083 Implant supported crown - porcelain fused to noble alloys

*D6084 Implant supported crown - porcelain fused to titanium and titanium alloys

*D6086 Implant supported crown - predominantly base alloys

*D6087 Implant supported crown - noble alloys

*D6088 Implant supported crown - titanium and titanium alloys

D6089 Accessing and retorquing loose implant screw - per screw

D6090 Repair of implant/abutment supported prosthesis

D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment

D6092 Re-cement or re-bond implant/abutment supported crown

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture

*D6094 Abutment supported crown – titanium and titanium alloys

D6096 Remove broken implant retaining screw

*D6097 Abutment supported crown - porcelain fused to titanium and titanium alloys

*D6098 Implant supported retainer - porcelain fused to predominantly base alloys

*D6099 Implant supported retainer for FPD - porcelain fused to noble alloys

D6100 Surgical removal of implant body

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure - Limited to once per implant, per lifetime.

D6104 Bone graft at time of implant placement

*D6110 Implant /abutment supported removable denture for edentulous arch – maxillary

*D6111 Implant /abutment supported removable denture for edentulous arch – mandibular

Current Dental Terminology © American Dental Association

*D6112 Implant /abutment supported removable denture for partially edentulous arch – maxillary

*D6113 Implant /abutment supported removable denture for partially edentulous arch – mandibular

*D6114 Implant /abutment supported fixed denture for edentulous arch – maxillary

*D6115 Implant /abutment supported fixed denture for edentulous arch – mandibular

*D6116 Implant /abutment supported fixed denture for partially edentulous arch – maxillary

*D6117 Implant /abutment supported fixed denture for partially edentulous arch – mandibular

*D6120 Implant supported retainer - porcelain fused to titanium and titanium alloys

*D6121 Implant supported retainer for metal FPD - predominantly base alloys

*D6122 Implant supported retainer for metal FPD - noble alloys

*D6123 Implant supported retainer for metal FPD - titanium and titanium alloys

*D6191 Semi-precision abutment - placement 

*D6192 Semi-precision attachment - placement 

*D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys

*D6195 Abutment supported retainer - porcelain fused to titanium and titanium alloys

*D7994 Surgical placement: zygomatic implant

Not covered:

• Any implant placement or removal, appliance placed on, or services associated with implants not specifically listed above.
• Any implant services or treatment provided primarily for cosmetic purposes.
• Initial placement of implants in edentulous arch when existing complete denture exists. (i.e. G.E.H.A will not upgrade the denture)

Sedation/Anesthesia/Inhalation of nitrous oxide/analgesia, anxiolysis - Deep sedation/general anesthesia, intravenous conscious sedation and inhalation of nitrous oxide/analgesia, anxiolysis are covered only when provided in connection with a covered procedure(s) and when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions. To be covered, the procedure for which deep sedation/general anesthesia, intravenous conscious sedation and inhalation of nitrous oxide/analgesia, anxiolysis was provided must be submitted along with a report of why anesthesia/analgesia was necessary. 

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia - Considered integral to all other oral evaluations or consultations. Only payable when anesthesia is payable.

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis - Not covered if performed in conjunction with D9222 Deep sedation/general anesthesia – first 15 minutes, D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment, D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes, D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment

D9610 Therapeutic parenteral drug, single administration – Therapeutic drug injections are not covered if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication. Coverage determined by report.

D9612 Therapeutic parenteral drugs, two or more administrations, different medications – Therapeutic drug injections are not covered if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication. Coverage determined by report. 

Current Dental Terminology © American Dental Association

D9613 Infiltration of sustained release therapeutic drug, per quadrant - When covered, D9613 Infiltration of sustained release therapeutic drug, per quadrant once per date of service for members up to age 22, when submitted with extractions (D7220 Removal of impacted tooth - soft tissue, D7230 Removal of impacted tooth - partially bony, D7240 Removal of impacted tooth - completely bony, D7241 Removal of impacted tooth - completely bony, with unusual surgical complications and D7251 Coronectomy - intentional partial tooth removal, impacted teeth only) not to exceed a maximum allowable of $300 per date of service.

D9930 Treatment of complications (post-surgical) - unusual circumstances, by report – Coverage determined by report. 

Cleaning and inspection of removable dentures which includes D9932 Cleaning and inspection of removable complete denture, maxillary, D9933 Cleaning and inspection of removable complete denture, mandibular, D9934 Cleaning and inspection of removable partial denture, maxillary and D9935 Cleaning and inspection of removable partial denture, mandibular are limited to once per Calendar year, not within 6 months of D1110 Prophylaxis - adult. These are considered integral if provided on the same date of service as D1110 Prophylaxis - adult.

D9932 Cleaning and inspection of removable complete denture, maxillary

D9933 Cleaning and inspection of removable complete denture, mandibular

D9934 Cleaning and inspection of removable partial denture, maxillary

D9935 Cleaning and inspection of removable partial denture, mandibular

D9941 Fabrication of athletic mouthguard – Limited to once per covered person per Calendar Year.

D9943 Occlusal guard adjustment - Limited to once per year.

Occlusal guards which includes D9944 Occlusal guard – hard appliance, full arch, D9945 Occlusal guard – soft appliance, full arch and D9946 Occlusal guard - hard appliance, partial arch are limited to once per Calendar Year for covered persons age 13 or older and treatment is for bruxism or to protect the teeth from grinding, chipping or fracture. An occlusal guard for temporomandibular joint dysfunction or other non-dental related treatment is not covered. Coverage determined by report.

D9944 Occlusal guard – hard appliance, full arch

D9945 Occlusal guard – soft appliance, full arch

D9946 Occlusal guard – hard appliance, partial arch

D9974 Internal bleaching – per tooth – Internal bleaching of discolored teeth is covered for endodontically treated anterior teeth once per covered person per tooth every 3 calendar years. External bleaching of discolored teeth is not a covered benefit.

*D9999 Unspecified adjunctive procedure, by report - The plan allowance will be determined upon review of the report.

Not covered:

• Precision attachments, personalization, precious metal bases, and other specialized techniques
• Replacement of dentures that have been lost, stolen or misplaced
• Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date
• Any exclusions or limitations listed under Section 7 of this plan document

Current Dental Terminology © American Dental Association

Orthodontic treatment is not covered if the initial placement of the appliance on the teeth was made prior to the current Coverage Effective Date of the covered person. Payment for orthodontic treatment will not be made until the appliance placement date has been submitted to us. 

Charges will be considered, subject to other plan conditions, as follows:

• The total case fee and the maximum allowed amount will be divided by the number of months for the total treatment plan. Each resulting portion will be considered to be incurred on a quarterly basis until the lifetime maximum is paid, treatment is completed or eligibility ends, whichever comes first.
  
  For example: When a provider bills $3,600 for a 24-month treatment plan including miscellaneous services, we will divide our allowable by 24 months ($3,600 divided by 24 months equals $150 per month). Our quarterly allowable will be $150 times 3 months or $450. Our allowable is reimbursed at 70% for a quarterly payment of $315. As the treatment plan is 24 months and we pay quarterly, we will process 8 quarterly payments, 7 payments at $315 and the last payment at $295, which equals $2,500 (your lifetime maximum). You will owe the difference between the billed amount and our payment ($3,600 less $2,500 equals $1,100).
• Verification that the covered person is still receiving active treatment is required from the provider once every 3 months.

D0340 2D cephalometric radiographic image – acquisition, measurement and analysis - Limited to once per lifetime.

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally - Limited once per lifetime.

D0470 Diagnostic casts - Limited to once per lifetime in conjunction with an ortho case and/or prior to treatment.

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent dentition

D8040 Limited orthodontic treatment of the adult dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8090 Comprehensive orthodontic treatment of the adult dentition

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) - All retention and case-finishing procedures are integral to the total case fee. Observations and adjustments are integral to the payment for retention appliances.

D8681 Removable orthodontic retainer adjustment - Limited to once per lifetime. Only considered when services are rendered by a dentist other than the dentist rendering complete orthodontic treatment.

Not covered:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliance
• Any exclusions or limitations listed under Section 7 of this plan document.
• Mail order or online orthodontic services and supplies or any treatment related to mail order orthodontic services and supplies.

Current Dental Terminology © American Dental Association

International services are services provided outside of the United States.  The dental plan provides care even when a member is outside of the United States.  Benefits and contract limits are the same for services received outside of the United States as for services received stateside.

To obtain emergency care while outside of the United States, you should see a covered provider and submit the bill for reimbursement.  This plan lets you choose your own dental practitioner.  This plan reimburses you or your provider for covered services.  We do not typically provide or arrange for dental care.

G.E.H.A’s in-network providers extend to the United States and U.S. Territories (Puerto Rico, Guam and the U.S. Virgin Islands).  In-Network providers do not extend outside of the United States other than the areas listed.  You have the right to choose any licensed dental practitioner; you do not need to contact G.E.H.A first. 

Note:  Because international claims do not have the consideration of stateside cost containment, members must be cautious to guard against inappropriate/excessive services.

G.E.H.A has a dedicated email address for our members outside the United States,
overseas.gehadental@geha.com. 

For services you receive outside of the United States, send a completed Dental Claim Form and the itemized bills to G.E.H.A Dental Claims, P. O. Box 21191, Eagan, MN 55121. Obtain Dental Claim Forms from www.geha.com/DentalForms. We will provide translation and currency conversion services for overseas (foreign) claim services. The conversion rate will be based on the date services were rendered.

Go to our website at www.geha.com or contact our Customer Service Department toll-free at (877) 434-2336 or TDD (800) 821-4833.

There is one international region.  Please see rate table for the actual premium amount.

For in-network provider claims, it is not necessary for members to file a claim.  The provider has agreed to do that for you.

For out-of-network provider claims, if you are a G.E.H.A FEHB/PSHB medical plan member, send dental claims to:

G.E.H.A Dental Claims 
P.O. Box 21191 
Eagan, MN 55121

If you are not a G.E.H.A FEHB/PSHB medical plan member, you must first submit your dental claim to your FEHB/PSHB medical plan, and then submit your dental claim to G.E.H.A, along with the FEHB/PSHB medical plan’s explanation of benefits (EOB).  If the EOB from your FEHB/PSHB medical plan is not submitted, we may estimate the amount they would have paid.

If you have other additional dental coverage, you must first submit your dental claim to your other dental plan(s), then submit your dental claim to G.E.H.A, along with the other plan’s explanation of benefits (EOB).

For claim filing assistance, call us toll-free at (877) 434-2336, or TDD (800) 821-4833.

When you must file a claim – such as for services you receive overseas or when another group health plan is primary – submit it on the ADA dental claim form or a claim form that includes the information shown below.  Bills and receipts should be itemized and show:

• Name of patient and relationship to member;
• Member identification number;
• Name, degree and address of the provider;
• Dates that services or treatment were received;
• Description of each service or treatment;
• Tooth number(s) and tooth surface(s) when applicable;
• Current Dental Terminology (CDT) procedure codes when applicable;
• Charge for each service or treatment.

We have the right to request additional information.  Canceled checks, cash register receipts or balance due statements are not acceptable substitutes for itemized bills.

Keep a separate record of the dental expenses of each covered person, as maximum benefit limits apply separately to each covered person.  Save copies of all dental bills.  In most instances, they will serve as evidence of your claim.  We will not provide duplicate or year-end statements.  For duplicate explanation of benefits (EOBs), you may visit our website at www.geha.com.  After creating a web account, you may view up to 18 months of your claim history.

Benefits may be assigned to a third party.  Any assignment will be effective on the date it is assigned, subject to any actions we may take prior to our receipt of the assignment.  We assume no responsibility for the validity of an assignment.  We have the right to pay the member or dental practitioner at our option, whether or not we receive an assignment of benefits.

If any benefits become payable to anyone who, in our opinion, is legally incapable of giving us a valid receipt or release, we may pay a portion of such benefits to any individual or institution we believe has assumed custody or principal support for such person, provided we have not received a request for payment from the person’s legal guardian or other legally appointed representative.

For services you receive outside of the United States, send itemized bills that include date the services were rendered.  Benefits will be calculated using the daily rate of exchange for the date of service and reimbursed in United States currency.  All international claims should be submitted to G.E.H.A Dental Claims, P. O. Box 21191, Eagan, MN 55121.

Please reply promptly when we ask for additional information.  We may delay processing or deny your claim if you do not respond.  See Section 6 International Services and Supplies for more information.

Send us all of the documents for your claims as soon as possible.  You must submit the claim by December 31 of the year after the year you receive the service, unless timely filing was prevented by administrative operations of the Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.  You must submit the requested information by December 31 of the year after you receive the service, for benefit determination. If submitted after this date, charges will not be considered for benefit payment. Once we pay benefits, checks are stale dated after 2 years. There is a 3-year limitation on the reissuance of uncashed checks.

We may, at our option, require supporting documentation such as clinical reports, charts, radiographic images, and study models.

Follow this disputed claims process if you disagree with our decision on your claim or request for services.  The FEDVIP law does not provide a role for OPM to review disputed claims.

Disputed Claim Steps:

1. Ask us in writing to reconsider our initial decision by requesting a formal appeal.  You must:

• Write to us within 6 months from the date of our decision; and
• Send your request to us by email: GEHADentalAppeals@geha.com, by fax: 866-963-0156, or by mail: G.E.H.A Post Service Appeals, P. O. Box 21324, Eagan, MN 55121; and
• Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
• Include copies of documents that support your claim, such as dentist’s letters, provider narratives, radiographic images or other records, and explanation of benefits (EOB) forms.

2. We have 30 days from the date we received your request to:

• Pay the claim (or, if applicable, arrange for the dental care provider to give you the care); or
• Write to you and maintain our denial – go to step 3; or
• Ask you or your provider for more information.  If we ask your provider, we will send you a copy of our request.  You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.  If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.  We will write to you with our decision.

3. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, final appeal to review the decision.  The decision of the independent third party is binding for us and is the final administrative review of your claim.  To request an independent third-party review you must:

• Write to us within 90 days of our letter maintaining denial; and
• Send your request to us by email: GEHADentalAppeals@geha.com, by fax: 866-963-0156 or by mail: G.E.H.A Post Service Appeal, P. O. Box 21324, Eagan, MN 55121; and
• Include a statement about why you are requesting an independent third-party final appeal review. This statement should include why you believe our decision to deny your claim was wrong, based on specific benefit provisions in this brochure; and include copies of documents that support your claim, such as dentist’s letters, provider narratives, X-rays or other records, and explanation of benefits (EOB) forms.

4. The independent third party will review your final appeal disputed claim request and will use the information sent by you, your provider and us to decide whether our decision is correct.  You will receive a copy of the third party’s final decision within 60 days.  The decision of the independent third party is binding and is the final review of your claim. This decision is not subject to judicial review.

Dental care that is:

• Medically necessary in the treatment of an otherwise covered medical (not dental) condition.
• An integral part of the treatment of such medical condition.
• Essential to the control of the primary medical condition.
• Required in preparation for or as the result of dental trauma, which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).

The maximum annual benefit that you can receive per person each calendar year.

Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity.  This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers.  Annuitants are sometimes called retirees.

Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and radiographic images. 

Intermediate services, which include restorative procedures such as restorations, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.

A covered provider is any licensed dentist, dental hygienist, or denturist acting within the scope of such license.

Covered services shall include only those services specifically listed in Section 5 Dental Services and Supplies.  A covered service must be incurred and completed while the person receiving the service is a covered person.  Covered services are subject to plan provisions for exclusions and limitations and meet acceptable standards of dental practice as determined by us.

Services or treatment performed by debarred providers.

A deductible is a fixed amount of expenses you must incur for certain covered services before we will pay for covered services. Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

Dental services that initiated in 2024 that will be completed in 2025.

The amount we use to determine our payment for out-of-network services.

This is the procedure used by the plan to estimate covered services and the amount that the plan will cover.  It is not a guarantee of payment.

If you change from one provider to another during the course of treatment, or if more than one provider performs the same covered service, we will provide the same amount of benefits as if there had been only one provider involved in your treatment.

For benefit determination purposes, we will use these dates as completion dates for the following covered services:

• Full or partial denture: the date the completed appliance is first inserted in the mouth.
• Inlay, onlay, crown or fixed bridge including, but not limited to, a Maryland bridge: the date the appliance is permanently cemented in place.
• Root canal therapy: the date the canal is permanently filled.
• Periodontal surgery: the date the surgery is actually performed.
• Any other service: the date the service is actually performed.

Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

If G.E.H.A pays benefits for an illness or injury for which you or your dependent are later compensated or reimbursed from another source, you must refund G.E.H.A from any recovery you or your dependent obtain.  All G.E.H.A benefit payments in these circumstances are conditional, and remain subject to our contractual benefit limitations, exclusions and maximums.

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members.

TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

G.E.H.A Connection Dental Federal^®.