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How is oral surgery covered under the dental plans? Oral Surgery is covered according to the dental plan provisions as long as they are not covered in whole or in part under your medical plan coverage. Therefore, when submitting a claim for oral surgery services to Aetna Dental, you must also include a copy of the Explanation of Benefits (EOB) from your medical plan for those services. Is a consult or second opinions for dental services, such as oral surgery, covered under the dental plans?
Dental consultations are not covered under the PPO or Out-of-Area dental plans. Under the DMO plan, you are eligible to receive a consultation or second opinion, but only by a participating specialist not performing the surgery. What are the differences between the DMO and the PPO/Out-of-Area Plans?
With the Dental Maintenance Organization (DMO) Plan, participants are covered for a broad range of services. Your copayments for covered services are "fixed" and are based on a "fixed" schedule. The DMO network is smaller when compared to the PPO network. However, there are over 22,000 DMO providers nationwide — making Aetna's DMO network the largest in the country. Additionally, discounts are greater than the PPO, ranging from 35-45 percent off average charges. With the Dental PPO and Out-of-Area Plans, you have the freedom to choose any licensed Dentist for covered expenses and pay deductibles and coinsurance up to an annual maximum. Generally, you will receive a higher level of benefits when you utilize an Aetna network dental provider. Aetna's PPO dental network includes over 63,000 dentists nationwide who provide, on average, a 27 percent discount off average charges.
Am I required to select a Primary Care Dentist?
In order to take advantage of covered benefits under the DMO Plan, participants must select a participating Primary Care Dentist (PCD). When you first enroll in the Aetna DMO, you will be prompted to select a PCD. Each family member can select a different participating Primary Care Dentist. The plan will not cover any services until you select a Primary Care Dentist. If you live in You are not required to choose a Primary Care Dentist under the PPO or Out-of-Area Plans. However, you are encouraged to use a personal dentist to coordinate your care. By using a personal dentist, you are establishing an ongoing relationship with a provider who is committed to getting to know you and your special needs.
Am I free to see any provider I choose, including specialists?
Under the DMO Plan, the Primary Care Dentist provides and coordinates the participant's care, referring participants to a dental specialist as appropriate under the terms of the plan. It is important to understand that a referral from your PCD is required and that services obtained without a referral from your PCD will not be covered. However, participants may visit network Orthodontists without a referral. With the Dental PPO and Out-of-Area Plans, you have the freedom to choose any licensed Dentist. Benefits are reduced under the Dental PPO Plan when you receive services from non-participating providers.
How do I find participating Aetna PPO and DMO dentists?
DocFind® , Aetna’s online provider directory, is easy to use and provides a comprehensive listing of participating DMO and Dental PPO dentists based upon your home zip code. If you do not have Internet access, you may also contact Aetna Member Services at 1-877-238-6200 for the DMO Plan or-1-800-843-3088 for the PPO Plan.
What are the advantages of using network dentists?
You are encouraged to take an active part in the decisions and management of your health before you receive treatment. You can save money by using participating providers. Generally, with the DMO Plan, you will not be covered for services with non-participating dentists. With the Dental PPO Plan, using participating providers will reduce your out-of-pocket costs:
What additional resources are available to dental plan enrollees?
Aetna gives you the tools to manage your dental benefits and access the dental health information that matters most to you. As a dental plan member, you can take advantage of these valuable online resources: Aetna Navigator: Aetna’s easy-to-use, self-service website is available 24 hours a day, 7 days a week. Once you enroll in a dental plan and register for Aetna Navigator you can:
Intelihealth: Want to know more about a dental procedure? Curious about when to expect your baby’s first tooth? Check out InteliHealth, Aetna’s online dental health resource at www.dental.intelihealth.com. This user-friendly website, backed by the
When you receive services, always make sure the provider of care has your Aetna identification number. As long as you receive services from a network provider, the provider will submit your claims for you. If you go to a provider outside of the network, you may have to file the claim yourself. In these situations, you must obtain an itemized billing from your provider of care. This itemized billing must contain the following information:
Your claim cannot be returned to you. If you need any of the itemized bills for your records, make a copy before mailing the claim. After you’ve received the itemized bills, you will need to complete a Claim form (available in the Dental Claim Kit section of About You) and forward it along with the itemized billing(s) to Aetna at the following address:
How can I check the status of a claim?
You can check the status of a claim that has been submitted to Aetna for processing by logging onto Aetna Navigator or by contacting Customer Service. The Customer Service number can be found on your ID card or an Explanation of Benefits (EOB).
When will claim payments be resolved? Generally, claims are processed within 10 days of the date on which Aetna receives them. However, some claims will take longer to process. If it has been more than 25 days since your claim was submitted for processing, contact Aetna Customer Service. The Customer Service number can be found on your ID card or an Explanation of Benefits (EOB). What is an Explanation of Benefits?
The Explanation of Benefits, frequently referred to as an "EOB," is used by Aetna to provide members with a record of how their claims were processed. It is generated for every claim processed on your policy and summarizes how Aetna administered your benefits when there is member responsibility for payment. Generally, the EOB shows covered and non-covered services. It will also indicate amounts applied toward deductible and coinsurance. When you receive services from a participating provider, the payment will be issued to the dentist’s office and you will receive notification of the payment, indicating your liability. If you have services from a non-participating provider, you or the provider may submit the claim, and you may instruct Aetna to reimburse you or the provider directly. You will receive an Explanation of Benefits, which will indicate the amount paid to the provider and the amount that you are responsible for paying. If a dental claim is paid in full and the member does not own any money to the provider, no EOB will be generated. What is the Alternate Procedures provision?
Sometimes a dental problem can be treated several ways. When this is the case, the Claims Administrator will pay benefits based on alternative procedures if Aetna, in its discretion, determines that alternative procedures are more appropriate and cost-effective. For example, dentists may use either a crown or a filling to restore a tooth. Also, dentists can select what material to use, such as precious metal or plastic. Whether or not you request a pre-determination of benefits, Aetna will pay the lower scheduled amount, provided the alternate procedure meets acceptable dental standards. When should I request a Pre-Determination of Benefits?
The Pre-Determination of Benefits provision enables you and your Dentist to know exactly how much the Aetna Dental PPO/Out-of-Area Plan will reimburse you for dental work before treatment begins. If you know dental expenses are going to exceed $350, you should ask your dentist to file for a Pre-Determination of Benefits by submitting the treatment plan and expected charges to Aetna for review. When benefits are pre-determined, both you and your dentist know in advance exactly what the Plan will pay toward your expenses. Please use the Aetna claim form for Pre-determination of Benefits. Contact Aetna Member Services at 1-800-843-3088 for more information. Will I receive letters or questionnaires asking about other insurance?
Most contracts include a provision for coordination of benefits with other health insurance carriers and a subrogation clause that allows Aetna to recover claim payments for services provided as a result of an illness or injury caused by a third party. The Aetna contract has exclusion for Workers’ Compensation claims. Aetna will collect information from you to update their records. If they send you a letter or a questionnaire asking if someone else is responsible to pay on your services, your timely response will ensure their quick release of any claims that are being researched. If a claim is denied for lack of information, please contact Customer Service and supply the missing information so they can reprocess your claim. How do I contact customer service?
You can contact Customer Service online by logging into or registering on the Aetna Navigator secure member website. You may also use he Aetna public Web form to send a request to Member Services. (Messages to the public Web address are retrieved during normal business hours.)
How are dental implants covered? Implants and oral surgery procedures related to surgical placement of a covered dental implant – including grafting and bone preparation, surgical removal, surgical placement and implant devices – are generally covered under the Verizon Business medical plans. The Verizon Business dental plans do not provide coverage for these services and only provide coverage for the crown over the implant. You must obtain approval from UnitedHealthcare and Aetna Dental prior to obtaining a recognized dental implant.
It is recommended that you request a Dental Predetermination of Benefits from For additional information on the implants and oral surgery related to surgical placement of a covered dental implant – including grafting, bone preparation, surgical removal, surgical placement and implant devices – contact UnitedHealthcare at 1-800-430-1449. |
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