D5110 Complete denture – maxillary – Limited to one in 5 years |
D5120 Complete denture – mandibular – Limited to one in 5 years |
D5130 Immediate denture – maxillary – Limited to one in 5 years |
D5140 Immediate denture – mandibular – Limited to one in 5 years |
D5211 Maxillary partial denture – resin base (including retentive clasping material, rests and teeth) – Limited to one in 5 years |
D5212 Mandibular partial denture – resin base (including retentive clasping material, rests and teeth) – Limited to one in 5 years |
D5213 Maxillary partial denture – cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – Limited to one in 5 years |
D5214 Mandibular partial denture – cast metal framework with resin denture base (including retentive/clasping materials,rests and teeth) – Limited to one in 5 years |
D5221 Immediate maxillary partial denture- resin base(including retentive/clasping materials,rests, and teeth) Limited to one in 5 years |
D5222 Immediate mandibular partial denture-resin based(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years |
D5223 Immediate maxillary partial denture-cast metal framework with resin denture bases(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years |
D5224 Immediate mandibular partial denture-cast metal framework with resin denture bases(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years |
D5225 Maxillary partial denture, flexible base - Limited to one in 5 years |
D5226 Mandibular partial denture, flexible base - Limited to one in 5 years |
D5227 immediate mandibular partial denture-flexible base(including clasps,rests, teeth)- Limited to one in 5 years |
D5228 Immediate mandibular partial denture-flexible base(including clasps,rests,teeth)- Limited to one in 5 years |
D5282 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials, rests and teeth), maxillary - Limited to one in 5 years |
Current Dental Terminology © American Dental Association |
D5283 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials, rests and teeth), mandibular- Limited to one in 5 years |
D5284 Removable unilateral partial denture-one piece flexible base(including retentive/clasping materials, rests and teeth) per quadrant - Limited to one in 5 years |
D5286 Removable unilateral partial denture- one piece resin(including retentive/clasping materials, rests and teeth) per quadrant - Limited to one in 5 years |
D5863 Overdentures complete maxillary |
D5864 Overdentures partial maxillary |
D5865 Overdentures complete mandibular |
D5866 Overdentures partial mandibular |
D5876 Add metal substructure to acrylic full denture - Limited to one in 5 years |
D5899 Unspecified removable prosthodontic procedure, by report |
D6012 Surgical placement of interim implant body for transitional prosthesis; endosteal implant – Dentally necessary only – Limited to one in 5 years |
D6058 Abutment supported porcelain/ceramic crown – Limited to one in 5 years |
D6059 Abutment supported porcelain/fused to metal crown(high noble metal) – Limited to one in 5 years |
D6060 Abutment supported porcelain/fused to metal crown (base metal) – Limited to one in 5 years |
D6061 Abutment supported porcelain/fused to metal crown (noble metal) – Limited to one in 5 years |
D6062 Abutment supported cast metal crown (high noble) – Limited to one in 5 years |
D6063 Abutment supported cast metal crown (base metal) – Limited to one in 5 years |
D6064 Abutment supported cast metal crown (noble metal) – Limited to one in 5 years |
D6065 Implant supported porcelain ceramic crown – Limited to one in 5 years |
D6066 Implant supported porcelain crown/fused to high noble alloys – Limited to one in 5 years |
D6067 Implant supported crown high noble alloys – Limited to one in 5 years |
D6080 Implant maintenance procedures when prostheses are removed and reinserted, cleansing of prosthesis, and abutments- Dentally necessary only – Limited to one in 5 years |
D6082 Implant supported crown- porcelain fused to predominantly base alloys - Limited to one in 5 years |
D6083 Implant supported crown-porcelain fused to noble alloys - Limited to one in 5 years |
D6084 Implant supported crown-porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
D6086 Implant supported crown, predominantly base alloys - Limited toone in 5 years |
D6087 Implant supported crown,noble alloys - Limited to one in 5 years |
D6088 Implant supported crown, titanium and titanium alloys - Limited to one in 5 years |
D6091 Replacement of replaceable part of semi-precision or precision attachment – Limited to one in 5 years |
D6094 Abutment supported crown, titanium and titanium alloys – Limited to one in 5 years |
D6097 Abutment supported crown, porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
D6102 Debridement of periimplant defect- Limited to one per tooth per lifetime |
D6210 Pontic – cast high noble metal – Limited to one in 5 years |
D6211 Pontic – cast predominately base metal – Limited to one in 5 years |
D6212 Pontic – cast noble metal – Limited to one in 5 years |
D6214 Pontic – titanium and titanium alloys – Limited to one in 5 years |
D6240 Pontic – porcelain fused to high noble metal – Limited to one in 5 years |
D6241 Pontic – porcelain fused to predominately base metal – Limited to one in 5 years |
D6242 Pontic – porcelain fused to noble metal – Limited to one in 5 years |
D6243 Pontic, porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
Current Dental Terminology © American Dental Association |
D6245 Pontic – porcelain/ceramic – Limited to one in 5 years |
D6545 Retainer – cast metal for resin bonded fixed prosthesis – Limited to one in 5 years |
D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis – Limited to one in 5 years |
D6549 Resin retainer - for resin bonded fixed prosthesis - Limited to one in 5 years |
D6601 Retainer inlay, porcelain/ceramic, three or more surfaces – Limited to one in 5 years |
D6602 Retainer inlay, cast high noble metal, two surfaces – Limited to one in 5 years |
D6603 Retainer inlay, cast high noble metal, three or more surfaces – Limited to one in 5 years |
D6604 Retainer inlay, cast predominantly base metal, two surfaces – Limited to one in 5 years |
D6605 Retainer inlay, cast predominantly base metal, three or more surfaces – Limited to one in 5 years |
D6606 Retainer inlay, cast noble metal, two surfaces – Limited to one in 5 years |
D6607 Retainer inlay, cast noble metal, three or more surfaces – Limited to one in 5 years |
D6613 Onlay, cast predominantly base metal, three or more surfaces – Limited to one in 5 years |
D6615 Onlay, cast noble metal, three or more surfaces – Limited to one in 5 years |
D6740 Retainer crown – porcelain/ceramic – Limited to one in 5 years |
D6750 Retainer crown – porcelain fused to high noble metal – Limited to one in 5 years |
D6751 Retainer crown – porcelain fused to predominately base metal – Limited to one in 5 years |
D6752 Retainer crown – porcelain fused to noble metal – Limited to one in 5 years |
D6753 Retainer crown, porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
D6780 Retainer crown – 3/4 cast high noble metal – Limited to one in 5 years |
D6781 Retainer crown – 3/4 cast predominately base metal – Limited to one in 5 years |
D6782 Retainer crown – 3/4 cast noble metal – Limited to one in 5 years |
D6783 Retainer crown – 3/4 porcelain/ceramic – Limited to one in 5 years |
D6784 Retainer crown 3/4, titanium and titanium alloys -Limited to one in 5 years |
D6790 Retainer crown – full cast high noble metal – Limited to one in 5 years |
D6791 Retainer crown – full cast predominately base metal – Limited to one in 5 years |
D6792 Retainer crown – full cast noble metal – Limited to one in 5 years |
D6794 Retainer crown, titanium and titanium alloys – Limited to one in 5 years |
D7994 Surgical placement: zygomatic implant - Limited to one in 5 years |
D7999 Unspecified oral surgery |
D9932 Cleaning and inspection of removable complete denture, maxillary- Limited to one in a 12 month period |
D9933 Cleaning and inspection of removable complete denture, mandibular - Limited to one in a 12 month period |
D9934 Cleaning and inspection of removable partial denture,maxillary - Limited to one in a 12 month period |
D9935 Cleaning and inspection of removable partial denture,mandibular - Limited to one per 12 month period |
Implant Services |
---|
Implant services may be allowed under the benefit plan. For the High Option we will limit payment on covered implant services to a calendar year maximum of $2,500. Replacement implant services are limited to one per 5 years after initial placement. |
D6010 Surgical placement of implant body:endosteal implant- Limited to one in 5 years |
D6011 Second stage implant surgery – Limited to one in 5 years |
D6013 Surgical placement of mini implant – Limited to one in 5 years |
D6040 Surgical placement; eposteal implant – Limited to one in 5 years |
D6050 Surgical placement; transosteal implant – Limited to one in 5 years |
D6052 Semi-precision attachment abutment |
Current Dental Terminology © American Dental Association |
D6055 Dental implant supported connecting bar- Limited to one in 5 years |
D6056 Prefabricated abutment – includes modification and placement – Limited to one in 5 years |
D6057 Custom fabricated abutment – includes placement – Limited to one in 5 years |
D6068 Abutment supported retainer/porcelain/ceramic fixed partial denture – Limited to one in 5 years |
D6069 Abutment supported retainer/porcelain/fused to metal (high noble) – Limited to one in 5 years |
D6070 Abutment supported retainer/porcelain/fused to metal fixed partial denture – Limited to one in 5 years |
D6071 Abutment support retainer/porcelain/fused to metal fixed partial denture(noble metal) – Limited to one in 5 years |
D6072 Abutment supported retainer/cast metal fixed partial denture(high noble) – Limited to one in 5 years |
D6073 Abutment supported retainer/cast metal fixed partial denture (base metal) – Limited to one in 5 years |
D6074 Abutment supported retainer/cast metal fixed partial denture (noble metal) – Limited to one in 5 years |
D6075 Implant supported retainer/ceramic fixed partial denture – Limited to one in 5 years |
D6076 Implant supported retainer fixed partial denture, porcelain fused to alloys - Limited to one in 5 years |
D6077 Implant supported retainer for metal fixed partial denture, high noble alloys – Limited to one in 5 years |
D6090 Repair implant supported prosthesis, by report – Limited to one in 5 years |
D6095 Repair implant abutment, by report – Limited to one in 5 years |
D6096 Remove broken implant retaining screw |
D6098 Implant supported retainer, porcelain fused to predominantly base alloys - Limited to one in 5 years |
D6099 Implant supported retainer for fixed partial denture, porcelain fused to noble alloys - Limited to one in 5 years |
D6100 Surgical removal of Implant, by report – Limited to one in 5 years |
D6104 Bone graft at time of placement - Limited to one per tooth per lifetime |
D6110 Implant/abutment support supported removable denture edentulous arch-maxillary-Limited to one in 5 years |
D6111 Implant/abutment supported removable denture for edentulous arch mandibular-Limited to one in 5 years |
D6112 Implant/abutment supported removable denture for partially edentulous arch-maxillary-Limited to one in 5 years |
D6113 Implant/abutment supported removable denture for partially edentulous arch-mandibular-Limited to one in 5 years |
D6114 Implant/abutment supported fixed denture for edentulous arch- maxillary – Limited to one in 5 years |
D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular – Limited to one in 5 years |
D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary – Limited to one in 5 years |
D6117 Implant/abutment supported fixed denture for partially edentulous arch- mandibular – Limited to one in 5 years |
D6120 Implant supported retainer, porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
D6121 Implant supported retainer for metal fixed partial denture, predominantly base alloy - Limited to one in 5 years |
D6122 Implant supported retainer for metal fixed partial denture, noble alloys - Limited to one in 5 years |
D6123 Implant supported retainer for metal fixed partial denture, titanium and titanium alloys - Limited to one in 5 years |
D6194 Abutment supported retainer crown for fixed partial denture – titanium and titanium alloys – Limited to one in 5 years |
D6195 Abutment supported retainer, porcelain fused to titanium and titanium alloys - Limited to one in 5 years |
D6198 Remove interim implant component - Limited to one in 5 years |
D7994 Surgical placement: zygomatic implant - Limited to one in 5 years |
Current Dental Terminology © American Dental Association |
Not covered:
- Implant services other than those listed above.
- 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 prescribed/initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date
|
Class D Orthodontic
Important things you should keep in mind about these benefits:
- Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care or treatment of a covered condition and meet generally accepted dental protocols.
- There is no calendar year deductible for the plan benefits.
- There are no waiting periods for High or Standard option.
- If orthodontic treatment is already in progress at the time of eligibility, the orthodontic benefit will be prorated based on the number of months remaining in the treatment plan, subject to coinsurance and the lifetime maximum.
- In progress orthodontic treatment for dependents of retiring TDP enrollees will be covered for the 2023 plan year. This is regardless of any current plan exclusions for care initiated prior to the enrollee's effective date. If orthodontic treatment is already in progress at the time of eligibility, the orthodontic benefit will be prorated based on the number of months remaining in the treatment plan, subject to coinsurance and the lifetime maximum.
- High Option lifetime maximum for orthodontic services (Class D) is $3,000 per covered person.
- Standard Option lifetime maximum for orthodontic services (Class D) is $2,000 for dependent children to age 19.
You Pay:
High Option
- In-Network: 50% of our network allowance
- Out-of-Network: 50% coinsurance plus the difference between the allowed amount and the provider’s charge.
Standard Option
- In-Network: 50% of our network allowance
- Out-of-Network: 50% coinsurance plus the difference between the allowed amount and the provider’s charge.
Details
Orthodontic Services |
---|
D0340 Cephalometric film - Limited to one per patient per lifetime |
D0350 Oral/facial images |
D0351 3D photographic image |
D0702 2-D cephalometric radiograhic image- Image capture only - Limited to one per member per lifetime |
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 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 |
Current Dental Terminology
© American Dental Association
|
D8220 Fixed appliance therapy |
D8660 Pre-orthodontic treatment examination to monitor growth and development |
D8670 Periodic orthodontic treatment visit |
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) |
D8681 Removable orthodontic retainer adjustment - Integral, not covered submitted as a separate service |
D8999 Unspecified orthodontic procedure |
Current Dental Terminology © American Dental Association |
Not covered:
- Repair of damaged orthodontic appliances
- Replacement of lost or missing appliance
- Orthodontic services for an enrolled member or dependent who has not met the 12 month waiting period requirement under the plan.
- 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
|
General Services
Important things you should keep in mind about these benefits:
- Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care or treatment of a covered condition and meet generally accepted dental protocols.
- There is no calendar year deductible for the plan benefits.
- High Option annual benefit maximum is Unlimited per covered person.
- Standard Option annual benefit maximum is $1,500 per covered person.
You Pay:
High Option
- In-Network: 20% of our network allowance
- Out-of-Network: 40% coinsurance plus the difference between the allowed amount and the provider’s charge.
Standard Option
- In-Network: 45% of our network allowance
- Out-of-Network: 60% coinsurance plus the difference between the allowed amount and the provider’s charge.
Details
Anesthesia Services |
---|
D9219 Evaluation for moderate sedation, deep sedation or general anesthesia - Limited to third molar extractions only, children up to age 22 and once per lifetime |
D9222 Deep sedation/general anesthesia – first 15 minutes – Covered by report |
D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment – Covered by report |
Intravenous Sedation |
---|
D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes- Covered by report |
D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment– Covered by report |
Consultations |
---|
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) |
Office Visits |
---|
D9440 Office visit – after regularly scheduled hours |
Medications |
---|
D9610 Therapeutic drug injection, by report |
D9612 Therapeutic parenteral drugs, two or more administrations, different medications |
Post Surgical Services |
---|
D9930 Treatment of complications (post-surgical) unusual circumstances, by report |
Current Dental Terminology © American Dental Association |
Miscellaneous Services |
---|
D9941 Fabrication of athletic mouthguard – Limited to one per 12 month period |
D9943 Occlusal Guard adjustment - Limited to one per 24 months for patients age 13 or over; not covered when performed for TMJ |
D9944 Occlusal guard, hard appliance,full arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ |
D9945 Occlusal guard, soft appliance,full arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ |
D9946 Occlusal guard, hard appliance, partial arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ |
D9974 Internal bleaching – per tooth – Limited to one per endodontically treated tooth per 3 year period
|
Not covered:
- Nitrous oxide
- Oral sedation
- Repair/reline of occlusal guard
|
Current Dental Terminology © American Dental Association |
Section 6 International Services and Supplies
Term | Definition |
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International Claims Payment | You will need to submit a claim form with a receipt to be reimbursed in U.S. dollars based on the current Citibank foreign exchange rate. |
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Finding an International Provider
|
If you live overseas, you may visit any dentist. You are responsible for submitting a claim form with a receipt.
|
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Filing International Claims | Submit the claim form and receipt to: United Concordia Companies, Inc. P.O. Box 69416 Harrisburg, PA 17106-9416 You can download a claim form from our website at www.uccifedvip.com. |
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Customer Service Website and Phone Numbers | You may contact Customer Service at 1-877-394-8224 or by visiting our website at www.uccifedvip.com. |
---|
International Rates
|
There is one international region. Please see the rate table for the actual premium amount.
|
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Section 7 General Exclusions – Things We Do Not Cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition.
We do not cover the following:
- Any dental service or treatment not specifically listed as a covered service;
- Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of their license and applicable state law;
- Services and treatment which are experimental or investigational;
- Services and treatment which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit. This exclusion applies whether or not you claim the benefits or compensation;
- Services and treatment for which the cost is later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law;
- Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group;
- Services and treatment initiated/prescribed or performed prior to your effective coverage date, orthodontic treatment prorated;
- Services and treatment incurred after the termination date of your coverage even if prescribed/initiated while covered;
- Services and treatment which are not dentally necessary, or which are not recommended or approved by the treating dentist (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to you by a participating dentist unless the dentist notifies you of your liability prior to treatment and you choose to receive the treatment. Participating dentists should document such notification in their records.);
- Services and treatment not meeting accepted standards of dental practice;
- Services and treatment performed by a debarred provider;
- Services and treatment resulting from your failure to comply with professionally prescribed treatment;
- Telephone consultations;
- Any charges for failure to keep a scheduled appointment;
- Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
- Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMJD);
- Services or treatment provided as a result of intentionally self-inflicted injury or illness;
- Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection;
- Office infection control charges;
- Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
- State or territorial taxes on dental services performed;
- Adjunctive dental care services that may be covered under the FEHB or other medical insurance even when provided by a general dentist or oral surgeon;
- Services or treatment provided by a member of your immediate family or a member of the immediate family of your spouse;
- Those submitted by a dentist which are for the same services performed on the same date for the same member by another dentist;
- Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
- Those for which the member would have no obligation to pay in the absence of this or any similar coverage;
- Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association;
- Those performed by a dentist who is compensated by a facility for similar covered services performed for members;
- Plaque control programs, oral hygiene instruction, and dietary instructions;
- 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, restoration for misalignment of teeth, or restoring tooth structure from attrition, erosion or abrasion;
- Gold foil restorations;
- Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan;
- Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization;
- Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient);
- Nitrous oxide;
- Oral sedation;
- All major prosthodontic services are combined under one replacement limitation under the plan. Benefits for prosthodontics services are combined and limited to one ever 5 years. For example, if benefits for a partial denture are paid, this includes benefits to replace all missing teeth in the arch. No additional benefits for the arch would be considered until the 5 year replacement limit was met.
Section 8 Claims Filing and Disputed Claims Processes
Term | Definition |
---|
How to File a Claim For Covered Services | A United Concordia participating Federal Dental Program Network dentist files the claim for you. If you do need to file a claim, you and the dentist should complete the appropriate claim form sections, and you should then mail the claim to the address below. You can download a claim form from our website at www.uccifedvip.com. United Concordia Companies, Inc. PO. Box 69416 Harrisburg, PA 17106-9416 |
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Deadline For Filing Your Claim | Your United Concordia Federal Dental Program Network participating dentist or you must file a claim within 12 months after the month in which a service is provided. |
---|
Term | Definition |
---|
Disputed Claims Process | 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 Claims Steps
- Ask us in writing to reconsider our initial decision. You must file an appeal with us within 180 days of receipt of the initial decision. Please submit with your appeal, the appropriate written comments from the treating dentist, supporting documents, dental records and other information relating to the claim(s).
- We have 60 days from the date we receive your request to review the appeal in a thorough, appropriate and timely manner to ensure that you are afforded a full and fair review of claims for benefits.
- If the dispute is not resolved through the reconsideration process, you may request a review of the denial. You must file the appeal to us within 30 days of the receipt of the first review decision. Any dentist advisor involved in reviewing the appeal will be different from and not in a subordinate position to the dentist advisor involved in the initial benefit determination.
- If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, to review the decision. You must file the appeal in writing to United Concordia Dental within 30 days of receipt of the original appeal decision. The appeal should be mailed, with the appropriate written comments from the treating dentist, supporting documents, dental records and other information relating to the claim(s) to:
United Concordia Companies, Inc. Member Appeals Department P.O. Box 69420 Harrisburg, PA 17106-9420
The independent third party will thoroughly review the appeal and provide the decision to United Concordia Dental who will in turn respond to you in writing within 60 days of receipt of the third party review request. 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. |
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Section 9 Definitions of Terms We Use in This Brochure
Term | Definition |
---|
Annual Benefit Maximum | The maximum annual benefit that you can receive per person each calendar year. For the High Option our Plan includes an annual benefit maximum of Unlimited and $2,500 annual benefit maximum for Implant Services, per covered person. For the Standard Option our Plan includes $1,500 annual benefit maximum per covered person. Once you reach this amount, you are responsible for all charges. |
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Annuitants
| 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. |
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BENEFEDS
| The enrollment and premium administration system for FEDVIP. |
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Benefits
| Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure. |
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Class A Services
| Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants and x-rays. |
---|
Class B Services
| Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments. |
---|
Class C Services
| Major services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges and prosthodontic services such as complete dentures. |
---|
Class D Services
| Orthodontic services. |
---|
Dental Accident
| An injury to sound natural teeth and supporting structures caused by a violent external force such as a fall or blow to the mouth. |
---|
Enrollee | The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan. |
---|
FEDVIP
| Federal Employees Dental and Vision Insurance Program. |
---|
Generally Accepted Dental Protocols
| "Conventional" methods of evaluation, diagnosis, prevention and/or treatment of diseases, conditions and/or dysfunctions relating to the oral cavity and its associated structures. |
---|
In-Progress Treatment | Dental services that initiated/prescribed or performed in 2022 that will be completed in 2023. |
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Plan Allowance | The amount we use to determine our payment for services. We determine our Plan allowance for members who reside in limited access areas as follows: the 75th percentile of Ingenix data for the provider’s location; for care provided to members who live outside of the 50 states, the District of Columbia or Puerto Rico, the 90th percentile of Ingenix data for the District of Columbia. |
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Pre-Determination | Pre-determination is not necessary under this Plan. However, we do recommend that you request a pre-determination of benefits for more extensive treatments. This will assure both you and your dentist that the service is covered and indicate how much you can expect to pay out-of-pocket. |
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Preexisting Condition
| Any disease or condition of the teeth or supporting structures which were present on the effective date of coverage. |
---|
Rating Areas
| 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. Your rates might change because of the move. |
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Sponsor | 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). |
---|
TEI certifying family member | 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 |
---|
TRICARE-eligible individual (TEI) family member | 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. |
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Waiting period
| The amount of time that you must be enrolled in this Plan before you can receive orthodontic services. |
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We/Us | United Concordia Dental. |
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You
| Enrollee or eligible family member. |
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Non-FEDVIP Benefits Available to Members
College Tuition Benefit®
Your United Concordia FEDVIP Dental plan includes the value-added College Tuition Benefit®, a discount program offered in partnership with SAGE Scholars, Inc. You’ll earn Tuition Rewards® points that can be redeemed for tuition discounts at more than 400 participating private colleges and universities.
How Tuition Rewards work
- Earn 2,000 Tuition Rewards points every year you’re covered by United Concordia Dental insurance.
- One Tuition Rewards point = $1, so 2,000 points = $2,000 in tuition discounts.
- Helps eligible students in the FEDVIP policyholder’s family afford college including children, grandchildren, nieces, nephews, stepchildren, godchildren and adopted children.
- Each child enrolled receives a one-time bonus of 500 Tuition Rewards points.
Sign up for Tuition Rewards
- Visit www.uccifedvip.com and login to your MyDentalBenefits account.
- Verify your email address is correct by clicking your name in the upper right hand corner. SAGE Scholars will use this to contact you.
- Click on Learn more in the Tuition Rewards notification bar above your benefits info.
- Click on the Get Started button and consent to participate.
- Look for a welcome email from SAGE Scholars and follow the instructions on how to register.
Tuition Rewards® is a Registered Trademark of SAGE Scholars, Inc. SAGE is not a subsidiary or affiliate of United Concordia Insurance Company (UCIC). Subject to eligibility requirements and terms and conditions. Tuition Rewards are a value-added program and not an insured benefit. Program participation subject to enrollment with SAGE. “Points” are credits that may be used to discount the cost of Tuition and have no cash value. UCIC does not provide services related to this program. Tuition Rewards not available in all jurisdictions. Program subject to change without notice.
GradFin
United Concordia Dental is introducing our FEDVIP members to GradFin, a student loan debt assistance program. GradFin’s student loan experts help members find the most efficient repayment and refinancing strategies for student loans. This program can improve the financial future of members by helping them pay off their student loans faster so they can start saving for the future. Employees, spouses and dependents can take advantage of GradFin services, which include:
- 1 on 1 consultations
- Financial education assistance
- Student loan refinancing assistance
- Public Service Loan Forgiveness assistance
To find out more about the GradFin services available to United Concordia Dental FEDVIP members, visit uccifedvip.com and click on GradFin.
20% off select Philips Sonicare products
FEDVIP members can save 20% on the electric toothbrushes, air flossers and replacement brush heads featured in United Concordia’s online Sonicare store. Electric brushes can remove 3x more plaque than manual toothbrushes.* In fact, they clean so effectively, it’s like a month’s worth of brushing in just 2 minutes.* To view eligible Sonicare products, click the Shop Now link on the uccifedvip.com homepage. A special discount code will be shown at the top of the page. Simply enter the code during checkout to get 20% off. *Philips Sonicare; 2021.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance Program premium.
Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
- Do not give your Plan identification (ID) number over the telephone or to people you do not know, except to your providers, Plan, BENEFEDS, or OPM.
- Let only the appropriate providers review your clinical record or recommend services.
- Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
- Carefully review your explanation of benefits (EOBs) statements.
- Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or service.
- If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 1-877-968-7455 and explain the situation.
- Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
- Your child over age 22 (unless he/she is disabled and incapable of self- support).
If you have any questions about the eligibility of a dependent, please contact BENEFEDS.
Be sure to review Section 1, Eligibility, of this brochure, prior to submitting your enrollment or obtaining benefits.
Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the Plan when you are no longer eligible.
Summary of Benefits
- Do not rely on this chart alone. This page summarizes specific expenses we cover; please review the individual sections of this brochure for more detail.
- If you want to enroll or change your enrollment in this Plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680.
High Option: Class A (Basic) Services – preventive and diagnostic *
You Pay In-network: 0%
You Pay Out-of-network: 20%
Page: 16
High Option: Class B (Intermediate) Services – includes minor restorative *
You Pay In-network: 20%
You Pay Out-of-network: 40%
Page: 18
High Option: Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services *
You Pay In-network: 50%
You Pay Out-of-network: 60%
Page: 22
High Option Benefits: Class D Orthodontic - a $3,000 lifetime maximum
You Pay In-network: 50%
You Pay Out-of-network: 50%
Page: 30
*Class A, B, and C Services are subject to an Unlimited annual maximum benefit for standard services and a $2,500 annual maximum on Implant Services; $2,000 dental accident lifetime maximum
Standard Option: Class A (Basic) Services – preventive and diagnostic *
You Pay In-network: 0%
You Pay Out-of-network: 40%
Page: 16
Standard Option: Class B (Intermediate) Services – includes minor restorative *
You Pay In-network: 45%
You Pay Out-of-network: 60%
Page: 18
Standard Option: Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services *
You Pay In-network: 65%
You Pay Out-of-network: 80%
Page: 22
Standard Option Benefits: Class D Orthodontic - subject to a $2,000 lifetime maximum
You Pay In-network: 50%
You Pay Out-of-network: 50%
Page: 30
*Class A, B, and C Services are subject to a $1,500 annual maximum benefit for standard services and $2,000 dental accident lifetime maximum
Rate Information
Rating Regions
State | zip | Region |
---|
AK | Entire state | 5 |
AL | Entire state | 1 |
AR | Entire state | 1 |
AZ | 864 | 4 |
AZ | Rest of state | 1 |
CA | 900-908, 910-918,922-931,933-935 | 3 |
CA | 939-941, 943-952, 954 | 5 |
CA | Rest of state | 4 |
CO | Entire state | 3 |
CT | Entire state | 5 |
DC | Entire state | 4 |
DE | Entire state | 2 |
FL | 330-334, 349 | 3 |
FL | Rest of state | 1 |
GA | Entire state | 1 |
HI | Entire state | 4 |
IA | Entire state | 1 |
ID | Entire state | 2 |
IL | 600-608, 609,613 | 3 |
IL | Rest of state | 1 |
IN | 463-464 | 3 |
IN | Rest of state | 1 |
KS | 660-662,666 | 1 |
KS | Rest of state | 2 |
KY | Entire state | 1 |
LA | Entire state | 1 |
MA | 012 | 3 |
MA | Rest of state | 5 |
MD | 219 | 2 |
MD | Rest of state | 4 |
ME | 039-042 | 5 |
ME | Rest of state | 3 |
MI | Entire state | 2 |
MN | 550-555, 563 | 3 |
MN | Rest of state | 2 |
MO | Entire state | 1 |
MS | Entire state | 1 |
MT | Entire state | 1 |
NC | 279 | 1 |
NC | Rest of state | 2 |
ND | Entire state | 1 |
NE | Entire state | 1 |
NH | Entire state | 5 |
NJ | 080-084 | 2 |
NJ | Rest of state | 5 |
NM | Entire state | 2 |
NV | Entire state | 4 |
NY | 005, 063, 100-119,124-126 | 5 |
NY | Rest of state | 3 |
OH | 440-443, 446-447 | 3 |
OH | 430-433, 437,453-455 | 2 |
OH | Rest of state | 1 |
OK | Entire state | 1 |
OR | 970-973 | 5 |
OR | Rest of state | 4 |
PA | 172-174 | 4 |
PA | 180-181, 183 | 5 |
PA | 189-196 | 2 |
PA | Rest of state | 1 |
PR | Entire state | 1 |
RI | Entire state | 5 |
SC | 297 | 2 |
SC | Rest of state | 1 |
SD | Entire state | 1 |
TN | Entire state | 1 |
TX | Entire state | 1 |
UT | Entire state | 3 |
VA | 201, 205, 220-227 | 4 |
VA | 230, 232, 238 | 2 |
VA | Rest of state | 1 |
VT | Entire state | 3 |
WA | 980-986 | 5 |
WA | Rest of state | 4 |
WI | 530-532, 534, 540 | 3 |
WI | Rest of state | 2 |
WV | 254 | 4 |
WV | Rest of state | 1 |
WY | Entire state | 2 |
VI | Entire area | 5 |
GU | Entire area | 5 |
Inter- national | | 5 |
APO/ FPO | | 5 |
Bi-weekly and Monthly Rates
High
Rating Area | High-Bi-Weekly Self Only | High-Bi-Weekly Self Plus One | High-Bi-Weekly Self and Family | High-Monthly Self Only | High-Monthly Self Plus One | High-Monthly Self and Family |
---|
1 | 16.53 | 33.06 | 49.56 | 35.82 | 71.63 | 107.38 |
2 | 18.55 | 37.09 | 55.64 | 40.19 | 80.36 | 120.55 |
3 | 20.60 | 41.17 | 61.78 | 44.63 | 89.20 | 133.86 |
4 | 22.63 | 45.25 | 67.88 | 49.03 | 98.04 | 147.07 |
5 | 24.66 | 49.31 | 73.95 | 53.43 | 106.84 | 160.23 |
Standard
Rating Area | High-Bi-Weekly Self Only | High-Bi-Weekly Self Plus One | High-Bi-Weekly Self and Family | High-Monthly Self Only | High-Monthly Self Plus One | High-Monthly Self and Family |
---|
1 | 9.64 | 19.28 | 28.92 | 20.89 | 41.77 | 62.66 |
2 | 10.83 | 21.63 | 32.45 | 23.47 | 46.87 | 70.31 |
3 | 12.00 | 23.99 | 35.98 | 26.00 | 51.98 | 77.96 |
4 | 13.16 | 26.32 | 39.49 | 28.51 | 57.03 | 85.56 |
5 | 14.33 | 28.65 | 42.98 | 31.05 | 62.08 | 93.12 |