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.

If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage will begin on January 1, 2024.  Premium deductions will start with the first full pay period beginning on/after January 1, 2024.  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 13, 2023 through midnight EST December 11, 2023.  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.

There is no waiting period associated with our plan option.

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.

Triple-S Salud, Inc. adopted and complies with the codification system and service description in accordance with the Current Dental Terminology (CDT) of the American Dental Association (ADA).

Every year we make the changes according to the ADA’s Council of Dental Benefit Programs that are the responsible for maintaining the CDT Code in accordance with ADA Bylaws, policies, and federal regulations.

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 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.

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 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 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 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). 
• Temporary/seasonal employees who does not meet the 130 hours per calendar month for 90 days.

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.com) 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 plans’ premiums may change for 2024.

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 (TEI), you may enroll in a dental and/or vision plan during the November 13, through midnight EST December 11, 2023, Open Season.  Coverage is effective January 1, 2024.

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; or
• an employee returning to service following a break in service of at least 31 days.
• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which BENEFEDS receives and confirms your enrollment.

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 the 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 and confirms 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 (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 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 and/or FEDVIP plans. 

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You must show it whenever you receive services from a plan provider.  Your ID card does not have an expiration date to ensure the continuity of services.

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 787-774-6081, TTY 787-792-1370, 1-800-716-6081 or write to us at Triple-S Salud, Inc. (Triple-S Salud), Customer Service Division, 1441 Roosevelt Avenue, San Juan, Puerto Rico 00920.  You may also request replacement cards through our Web site at www.ssspr.com.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB 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.

We list plan providers in the provider directory, which we update periodically.  The list is on our Web site at: www.ssspr.com or you may call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081 .

The primary care dentists are duly authorized plan dentists with a regular license issued by the designated entity of the government of Puerto Rico, and who are bona fide members of the “Colegio de Cirujanos Dentistas de Puerto Rico”, who have signed a contract with Triple-S Salud, Inc. to render dental services.

We will only reimburse out-of-network services when rendered by orthodontists.  No other services rendered by out-of-network providers are covered including emergency services performed by an out-of-network dentist.  If you receive dental services from other out-of-network providers, services are not covered and you will have to pay 100% of the charges and we will not reimburse you.

Emergency services performed by an out-of-network dentist are not covered.  You will have to pay 100% of the charges and we will not reimburse you.

Some of the objectives of the pre-determination of benefits are to allow both the participant and the insured to confirm beforehand the eligibility of the service for the dental coverage, the scope of the covered services, limits, exclusions, necessity and deductibles and coinsurances applicable under the insureds contract. Pre-determinations will be evaluated based on the pre-determination policies that Triple-S Salud, Inc. has established. We will not be liable for payment of services, if they have been rendered or received without this pre-authorization/pre-determination.

The following dental benefits will require a pre-authorization/pre-determination of benefits: all crowns, fixed and removable prostheses, periodontal procedures and endodontic retreatments.

The dentist is responsible for the pre-determination of benefits and will list all services of the treatment plan on the ADA claim form and include radiographs and a report with the clinical evaluation justifying the necessity for the services.  The dentists will submit the form by paper or electronically.  For questions regarding this process, call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081.

When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first. The FEDVIP plan allowance will be the prevailing charge in these cases.  You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance.  We are responsible for facilitating the process with the FEHB first payor.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB 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.

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. 

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB 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.

We may request that you verify/identify your health insurance plan(s) annually or at time of service.  

To enroll in this plan, you must live in our service area.  This is where our providers practice.  Our service area is only Puerto Rico.

You must get your care from providers within the service area who contract with us.  If you receive care outside our service area, you will have to pay 100% of the charges.  We will not pay for services out of our service area.

If you move outside of our service area, you may enroll in another plan at that time.  You do not have to wait until Open Season to change plans. 

Contact BENEFEDS at www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to change plans.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our plan, you pay 15% of our allowance for oral surgery.

There is no benefit payable for out-of-network services other than for orthodontia.  You pay 100% of the billed charges.  We will not reimburse you.  Orthodontic services are reimbursed at 55% up to a lifetime maximum of $2,000 per member.

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 2024 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 2024 plan year such as crowns and implants. 

D0120 Periodic oral evaluation - Limited to twice every 12 months, with an interval of 6 months

D0140 Limited oral evaluation - problem focused - Limited to twice every 12 months, with an interval of 6 months

D0180 (P) Comprehensive periodontal - Limited to twice every 12 months, with an interval of 6 months

D0210 Intraoral - complete series (including bitewings)

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

D0251 Extra-oral -  posterior dental radiographic image

D0460 Pulp vitality test

D0999 Unspecified diagnostic procedure, by report

(P) = Services will be paid only to periodontists

D1206 Topical application of fluoride varnish

D1351 Sealant - per tooth - Limited to permanent molars and premolars through age 14; one sealant per tooth for life

D1516 Space maintainer fixed-bilateral- maxillary

D1517 Space maintainer-fixed-bilateral mandibular

D1520 Space maintainer - removable- unilateral 

D1526 Space maintainer - removable bilateral - maxillary

D1527 Space maintainer - removable bilateral - mandibular

D1551 Re-cementation or re-bond bilateral space maintainer - maxillary

D1552 Re-cementation or re-bond bilateral space maintainer - mandibular

D1553 Re-cement or re-bond unilateral space maintainer-per quadrant

D1556 Removal of fixed bilateral space maintainer per quadrant

D1557 Removal of fixed bilateral space maintainer maxillary 

D1558 Removal of fixed bilateral space maintainer mandibular

D9430 Office visits during regularly scheduled hours

D9995-D9996 Teledentistry - synchronous; real time encounter and asynchronous; information stored and forwarded to dentist for subsequent review

Not covered:

• Plaque control programs
• Oral hygiene instruction
• Dietary instructions
• Over-the-counter dental products, such as teeth whiteners, toothpaste, dental floss
• Services rendered by out-of-network providers
• Services not listed as covered above

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)

D2799 Provisional crown

D2920 Recement crown - Limited to one per patient, per tooth, per lifetime

D2930 Prefabricated stainless steel crown - primary tooth - Limited to one per patient, per tooth, per lifetime

D2950 Core buildup, including any pins

D2951 Pin retention - per tooth, in addition to restoration

D2980 Crown repair, by report

D2999 Unspecified restorative procedure, by report

Not Covered:

• Restorations, including veneers, which are placed for cosmetic purposes only 
• Gold foil restorations
• Services rendered by out-of-network providers
• Services not listed as covered above

D3220 Therapeutic pulpotomy (excluding final restoration)

D3221 Pulpal debridement, primary and permanent teeth

D3310 Endodontic therapy - anterior tooth (excluding final restoration)

D3320 Endodontic therapy - bicuspid tooth (excluding final restoration)

D3330 Endodontic therapy - molar (excluding final restoration)

D3346 Retreatment of previous root canal therapy-anterior

D3347 Retreatment of previous root canal therapy-bicuspid

D3348 Retreatment of previous root canal therapy-molar

D3351 Apexification recalcification - inicial

D3352 Apexification recalcification - interim 

D3353 Apexification recalcification - final visit

D3410 Apicoectomy - anterior

D3421 Apicoectomy - bicuspid (first root)

D3425 Apicoectomy - molar (first root)

D3426 Apicoectomy (each additional root)

D3430 Retrograde filling-per root

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

D3911 Intraorifice barrier (not to be used as a final restoration)

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

D3999 Unspecified endodontic procedure, by report

D4910 Periodontal maintenance

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 (each tooth)

D5611 Repair resin partial denture base - mandibular

D5612 Repair resin partial denture base - maxillary

D5621 Repair cast framework - mandibular

D5622 Repair cast partial framework - maxillary

D5630 Repair or replace broken clasp

D5640 Replace broken teeth - per tooth

D5650 Add tooth to existing partial denture

D5660 Add clasp to existing partial denture

D5710 Rebase complete maxillary denture

D5711 Rebase complete mandibular denture

D5720 Rebase maxillary partial denture

D5721 Rebase mandibular partial denture

D5725 Rebase hybrid prosthesis (to replace base material connected to framework)

D5730 Reline complete maxillary denture (chairside)

D5731 Reline complete mandibular denture (chairside)

D5740 Reline maxillary partial denture (chairside)

D5741 Reline mandibular partial denture (chairside)

D5750 Reline complete maxillary denture (laboratory)

D5751 Reline complete mandibular denture (laboratory)

D5760 Reline maxillary partial denture (laboratory)

D5761 Reline mandibular partial denture (laboratory)

D5765 Soft liner for complete or partial removable denture – indirect

D6930 Recement fixed partial denture

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

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

D7220 Removal of impacted tooth - soft tissue

D7230 Removal of impacted tooth - partially bony

D7240 Removal of impacted tooth - completely bony

D7250 Surgical removal of residual tooth roots (cutting procedure)

D7280 Surgical access of an unerupted tooth

D7283 Placement of device to facilitate eruption of impacted tooth

D7286 Biopsy of oral tissue - soft

D7310 Aveoplasty in conjunction with extractions four or more teeth or tooth spaces

D7311 Aveoplasty in conjunction with extractions one to three teeth or tooth spaces

D7320 Aveoplasty not in conjunction with extractions four or more teeth or tooth spaces

D7321 Aveoplasty not in conjunction with extractions one to three teeth or tooth spaces

D7510 Incision and drainage of abscess - intraoral soft tissue

D7471 Removal of lateral exostosis

D7472 Removal of torus palatinus

D7473 Removal of torus mandibular

D7971 Excision of pericoronal gingiva

D7999 Unspecified surgical procedure, by report

D2740 Crown - porcelain / ceramic 

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 predominately base metal

D2783 Crown - 3/4 porcelain/ceramic

D2790 Crown - full cast high noble metal

D2791 Crown - full cast predominately base metal

D2792 Crown - full cast noble metal

D2794 Crown - titanium

D2952 Cast post and core in addition to crown

D2954 Prefabricated post and core in addition to crown

Not covered:

• Gold foil restorations
• Restorations for cosmetic purposes only
• Composite resin inlays
• Services rendered by out-of-network providers
• Implants will not be covered where there are no teeth in either extremity.
• Services not listed as covered above

D4276 Combined connective tissue and double pedicle graft, per tooth 

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 

D4286 Removal of non-resorbable barrier

D5110 Complete denture - maxillary

D5120 Complete denture - mandibular

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

D5214 Mandibular partial denture - cast metal framework with resin denture base (including any conventional clasps, rests and teeth)

D5221 Immediate partial denture-resin base - maxillary 

D5222 Immediate partial denture-resin base - mandibular

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

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

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

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

D5282 Removable unilateral partial denture-one piece cast metal-maxillary

D5283 Removable unilateral partial denture-one piece cast metal-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 clasps and teeth)-per quadrant

D5899 Unspecified removal prosthodontic procedure, by report 

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)

D6075 Implant supported retainer for ceramic FPD

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

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 or titanium alloys

D6085 Provisional implant crown

D6086 Implant supported crown-predominantly base alloys

D6087 Implant supported crown-noble alloys

D6088 Implant supported crown-titanium and titanium alloys

D6090 Repair implant prosthesis, by report

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

D6097 Abutment supported crown-porcelain fused to titanium or titanium alloys

D6105 Removal of implant body not requiring bone removal or flap elevation

D6191 Semi-precision abutment - placement

D6192 Semi-precision attachment - placement

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

D6197 Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant

D6210 Pontic - cast high noble metal

D6211 Pontic - cast predominantly base metal

D6212 Pontic - cast noble metal

D6214 Pontic-titanium

D6240 Pontic - porcelain fused to high noble metal

D6241 Pontic - porcelain fused to predominately base metal

D6242 Pontic - porcelain fused to noble metal

D6243 Pontic-porcelain fused to titanium and titanium alloys

D6245 Pontic - porcelain/ceramic

D6253 Provisional pontic

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis

D6624 Inlay - titanium

D6634 Onlay - titanium

D6740 Crown - porcelain/ceramic

D6750 Crown - porcelain fused to high noble metal

D6751 Crown - porcelain fused to predominately base metal

D6752 Crown - porcelain fused to noble metal

D6753 Retainer crown - porcelain fused to titanium and titanium alloys

D6780 Crown - 3/4 cast high noble metal

D6781 Crown - 3/4 cast predominately base metal

D6782 Crown - 3/4 cast noble metal

D6783 Crown - 3/4 porcelain/ceramic

D6784 Retainer crown 3/4 - titanium and titanium alloys

D6790 Crown - full cast high noble metal

D6791 Crown - full cast predominately base metal

D6792 Crown - full cast noble metal

D6794 Crown - titanium

D6920 Connector bar

D6940 Stress breaker

D6950 Precision attachment

D9944 occlusal guard – hard appliance, full arch

D9945 occlusal guard – soft appliance, full arch

D9946 occlusal guard – hard appliance, partial arch

D9950 Occlusion analysis - mounted case

Not covered:

• Cast unilateral removable partial dentures
• 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
• Services rendered by out-of-network providers
• Services not listed as covered above

D8210 Removable appliance therapy, limited to once per lifetime

D8220 Fixed appliance therapy, limited to once per lifetime

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer (s)), limited to each per lifetime

D8690 Orthodontic treatment (alternate billing to a contract fee); initial payment for insertion of appliance, limited to once per lifetime

D8695 Removal of fixed orthodontic appliances for reasons other than completion of treatment, covered under the benefit maximum

Not covered:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliance
• Services to alter vertical dimension and/or restore or maintain the occlusion.  Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth
• Services not listed as covered above

D9230 Inhalation of nitrous oxide / analgesia, anxiolysis

D9630 Drugs or medicaments dispensed in the office for home use

D9910 Application of desensitizing medicament

D9951 Occlusal adjustment - limited

D9952 Occlusal adjustment - complete

D9999 Unspecified adjunctive procedure, by report

Not covered:

• Oral sedation
• Services rendered by out-of-network providers
• Services not listed as covered above

When you see plan providers, you will not have to file claims.  Just present your identification card and pay your coinsurance.

You will only need to file a claim when you receive orthodontic services.  You will have to submit the claim within one (1) year since the date of service. Sometimes these providers bill us directly.  Check with the provider.  If you need to file the claim, here is the process:

1. Claims for orthodontic reimbursement: In most cases, providers file claims for you.   Dentists must file an ADA claim form.  For claims questions and assistance, call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081.  When you receive orthodontic services, you must file an ADA claim form or a claim that includes the information shown below.  Bills and receipts should be itemized and:

        (a) Must be sent to: Triple-S Salud, Inc. PO Box 363628, San Juan, PR 
             00936-3628; and

        (b) Verify that the receipts have the information about the dentist printed on it 
              and that the name of the insured agrees with the contract number.  The
              Request for Reimbursement Form will be accepted as a receipt as long
              as it has the dentist information printed; the dentist’s signature and 
              their license number.

        (c) When requesting reimbursement for the first time, the insured must include:

                            • the treatment plan detailing the first visit
                            • down payment
                            • monthly payments
                            • total cost
                            • duration of treatment

        (d) Receipts must agree with what was established in your treatment plan.

        (e) If the insured pays more than one visit in the same receipt, he/she must 
              send the exact dates (month, day, and year) of the services for which he/she paid.

        (f) Payments in advance or total payment of the treatment will not be considered for 
             reimbursement.

        (g) If you pay for retainers, it must be indicated if they are mandibular or maxillary.

        (h) If you request reimbursement for orthodontic devices, it must be indicated if they 
              are fixed (D8220) or removable (D8210).

        To request reimbursement through Coordination of Benefits add:

                           • Contract number of the other plan
                           • If the reimbursement is for amounts left unpaid by your other 
                             plan, you must include the other plan’s Explanation of Benefits.

2. We have a period of 30 days after our receipt of the claim to:

        (a) Notify you of our determination.

        (b) Request additional information.  You will have up to 60 days to provide the 
              requested information.

        (c) Inform you that more time is needed to make a decision.  This extension may 
             consist of a maximum of 15 additional days.

Send us all the documents for your claim as soon as possible.  You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

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.  You must:
   • Write to us within the 180 days from the date of our determination.
   • Include in your letter the reason why you believe that the initial determination is incorrect.
   • Enclose copies of the documents that support your claim, such as a letter from the dentists, and the explanations of benefits.
   • Submit your written complaint to the following address: Triple-S Salud, Inc., Customer Service Division, Complaints and Grievances Unit, PO Box 363628, San Juan, PR 00936-3628.
2. We will notify you about our decision on your complaint no later than 30 days from the date your complaint was received.  If we need more time to make our decision, we will notify you in writing.  In said cases, the term to answer your complaint will not exceed a period of 15 days.
3. If the dispute is not resolved through the reconsideration process, you may request a review of the denial.  You may request a reconsideration within 60 days from the date you received the notification of our determination.  You may send your reconsideration request to the same address to which you sent your complaint.  In your reconsideration request, you must include the reason(s) why you understand Triple-S Salud was mistaken in its initial determination.  We must answer your request for reconsideration with a term of 30 days.
4. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, review the decision.  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.

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

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).

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.

Dental services that initiated in 2023 that will be completed in 2024.