MD9805 (02/13)
United Concordia Dental Plans, Inc.
4401 Deer Path Road
Harrisburg, PA 17110
Dental Plan
Certificate of Coverage
State of Maryland
MD9805 (02/13)
CERTIFICATE OF COVERAGE
INTRODUCTION
This Certificate of Coverage provides information about Your dental coverage. Read it carefully and keep it in
a safe place with Your other valuable documents. Review it to become familiar with Your benefits and when
You have a specific question regarding Your coverage.
To offer these benefits, Your Group has entered into a Group Contract with United Concordia. The benefits
are available to You as long as the Premium is paid and obligations under the Group Contract are satisfied.
In the event of conflict between this Certificate and the Group Contract, the Group Contract will rule. This
Certificate is not a summary plan description under the Employee Retirement Income Security Act (ERISA).
If You have any questions about Your coverage or benefits, please call our Customer Service Department
toll-free at:
(888) 638-3384
For general information, In-Network Dentist or benefit information, You may also log on to our website at:
www.unitedconcord ia.com
Claim forms should be sent to:
United Concordia Companies, Inc.
Dental Claims
PO Box 69422
Harrisburg, PA 17106-9422
MD9805 (02/13)
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TABLE OF CONTENTS
DEFINITIONS ................................................................................................................................................... 3
ELIGIBILITY AND ENROLLMENT .......................................................................................................................... 6
HOW THE DENTAL PLAN WORKS ..................................................................................................................... 8
CONTINUITY OF CARE ...................................................................................................................................... 9
BENEFITS ...................................................................................................................................................... 10
ALTERNATE TREATMENT ................................................................................................................................ 11
WORKER'S COMPENSATION & OTHER GOVERNMENTAL PROGRAMS ................................................................ 14
TERMINATION ................................................................................................................................................ 14
CONTINUATION OF COVERAGE ....................................................................................................................... 15
CONVERSION OF COVERAGE .......................................................................................................................... 15
GENERAL PROVISIONS ................................................................................................................................... 15
PRIVACY AND CONFIDENTIALITY OF DENTAL RECORDS ................................................................................... 16
RIGHTS OF COMPANY TO CHANGE PLAN......................................................................................................... 16
ATTACHED:
APPEAL PROCEDURE ADDENDUM
SCHEDULE OF BENEFITS
SCHEDULE OF EXCLUSIONS AND LIMITATIONS
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DEFINITIONS
Certain terms used throughout this Certificate begin with capital letters. When these terms are capitalized,
use the following definitions to understand their meanings as they apply to Your benefits and the way the
dental Plan works.
Certificate Holder(s) - An individual who, because of his/her status with the Contractholder, has enrolled
him/herself and/or his/her eligible Dependents for dental coverage and for whom Premiums are paid. In the
case of a Group Contract that covers only dependent children, the Certificate Holder must be the child’s or
children’s parent, stepparent, grandparent, legal guardian, or legal custodian, Also referred to as “You” or
“Your” or “Yourself”.
Certificate of Coverage (“Certificate”) - This document, including riders, schedules, addenda and/or
endorsements, if any, which describes the coverage purchased from the Company by the Contractholder.
Company –United Concordia Dental Plans, Inc.
Contractholder - Organization that executes the Group Contract. Also referred to as “Your Group”.
Contract Year - The period of twelve (12) months beginning on the Group Contract’s Effective Date or the
anniversary of the Group Contract’s Effective Date and ending on the day before the Renewal Date.
Coordination of Benefits (“COB”) - A method of determining benefits for Covered Services when the
Member is covered under more than one plan. This method prevents duplication of payment so that no more
than the incurred expense is paid.
Copayments - Those amounts set forth in the Schedule of Benefits that the Member is responsible to pay
the treating Dentist.
Cosmetic - Those procedures which are undertaken primarily to improve or otherwise modify the Member's
appearance.
Covered Service(s) - Services or procedures shown on the Schedule of Benefits for which benefits will be
covered subject to the Schedule of Exclusions and Limitations, when rendered by In-Network Dentists in
accordance with the terms of this Certificate.
Dental Emergency - An acute condition occurring suddenly and unexpectedly, which usually includes pain,
swelling or bleeding, and demands immediate professional dental services.
Dentist(s) - A person licensed to practice dentistry in the state in which dental services are provided. Dentist
will include any other duly licensed dental professional practicing under the scope of the individual’s license
when state law requires independent reimbursement of such practitioners.
Dependent(s) - Those individuals eligible to enroll for coverage under the Group Contract because of
their relationship to the Certificate Holder.
This Group Contract is a Family Contract. Dependents eligible for coverage in this Family Contract
include:
1. The Certificate Holder’s Spouse and
2. Any unmarried natural child, stepchild, grandchild, adopted child or child placed with the
Certificate Holder or the Certificate Holder’s Spouse or domestic partner:
(a) until the end of the month; that the child reaches age twenty six (26); or
(b) to any age if the child is and continues to be both incapable of self-sustaining employment
by reason of mental or physical incapacity and chiefly dependent upon the Certificate Holder
for support
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3. Any unmarried natural child, stepchild, grandchild, adopted child or child placed for adoption
with the Certificate Holder or the Certificate Holder’s Spouse or domestic partner by order of a
court or administrative agency, subject to 3 a-c above. In this case:
a. the insuring parent shall be allowed to enroll in a family members' coverage and include the
child in that coverage regardless of enrollment period restrictions;
b. if the insuring parent is enrolled in health insurance coverage but does not include the child in
the enrollment, then:
(i)The non-insuring parent, child support enforcement agency, or Department of Health and
Mental Hygiene may apply for enrollment on behalf of the child; and
(ii) include the child in the coverage regardless of enrollment period restrictions; and
c. We will not terminate health insurance coverage for the child unless written evidence is
provided to the entity that:
(i) the order is no longer in effect;
(ii) the child has been or will be enrolled under other reasonable health insurance coverage
that will take effect on or before the effective date of the termination;
(iii) the employer has eliminated family members' coverage for all of its employees; or
(iv) the employer no longer employs the insuring parent, except that if the parent elects to
exercise the provisions of the federal Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA), coverage shall be provided for the child consistent with the employer's plan
for postemployment health insurance coverage for dependents.
4. Any unmarried natural child, stepchild, grandchild, by order of a court or administrative agency
subject to 3 a-c above, who is under testamentary or court appointed guardianship, other than
temporary guardianship of less than 12 months duration, of the insured, subscriber, employee, or
member.
Effective Date - The date on which the Group Contract begins or coverage of enrolled Members begins.
Exclusion(s) – Services, supplies or charges that are not covered under the Group Contract as stated in the
Schedule of Exclusions and Limitations.
Experimental or Investigative - The use of any treatment, procedure, facility, equipment, drug, or drug
usage device or supply which the Company, determines is not acceptable standard dental treatment of the
condition being treated, or any such items requiring federal or other governmental agency approval which
was not granted at the time the services were rendered. The Company will rely on the advice of the general
dental community including, but not limited to dental consultants, dental journals and/or governmental
regulations, to make this determination.
Family Contract - A Group Contract that covers the Contractholder’s Certificate Holders and may also cover
eligible Dependents, as defined in this Evidence of Coverage. A Group Contract that covers only
Subscribers’ children is not a Family Contract.
Grace Period - A period of thirty (30) days granted for payment of each premium due after the first
premium, unless the dental plan organization does not intend to renew the contract beyond the period for
which premium has been accepted and notice of the intention not to renew is delivered to the contract
holder at least forty-five (45) days before the premium is due. During the grace period the contract shall
continue in force.
Group Contract - The agreement between the Company and the Contractholder, under which the Certificate
Holder is eligible to enroll him/herself and/or his/her Dependents.
In-Network Dentist – A Primary Dental Office or a Specialty Care Dentist.
Limitation(s) - The maximum frequency or age limit applied to a Covered Service set forth in the Schedule
of Exclusions and Limitations incorporated by reference into this Certificate.
.
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Maryland Health Connection – The Health Insurance Marketplace authorized by law or regulation in the
state of Maryland through which individuals and groups can purchase insurance to meet the requirements of
the federal Affordable Care Act. Maryland Health Connection also refers to any successor Maryland Health
Insurance Marketplace established under the federal Affordable Care Act.
Member(s) – Enrolled Certificate Holder(s) and their enrolled Dependent(s). Also referred to as “You” or
“Your” or “Yourself”.
Out-of-Network Dentist - A general or specialty care Dentist who has not signed a contract Us. Also
referred to as “Non-Participating Provider.”
Out-of-Pocket Expense(s) - Cost not paid by Us, including but not limited to Copayments, amounts billed by
Out-of-Network Dentists except as specified in the Dental Emergencies and Out-of-Network Care provision
of this Certificate, costs of services that exceed the Group Contract’s Limitations, Annual Maximum or
Lifetime Maximums, or for services that are Exclusions. The Certificate Holder is responsible for Out-of-
Pocket Expenses.
Out-of-Pocket Maximum - The limit on Copayments and Deductibles from Primary Dentists and Specialty
Care Dentists that the Certificate Holder is required to pay in a Contract Year, as shown on the Schedule of
Benefits. After this limit is reached, Covered Services from Primary Dental Providers and Specialty Care
Dentists is paid 100% by the Plan for the remainder of the Contract Year, subject to the Schedule of
Exclusions and Limitations.
Plan - Dental benefits pursuant to this Certificate and attached Schedule of Exclusions and Limitations and
Schedule of Benefits.
Premium - Payment made by the Contractholder in exchange for coverage of the Contractholder’s Members
under this Group Contract.
Primary Dental Office/Provider - Approved office of a Primary Dentist who has executed a contract with Us
to offer Covered Services to Members.
Primary Dentist - A general Dentist whose office has executed a contract with Us, under which he/she
agrees to provide Covered Services to Members for a monthly fee plus any applicable supplements and
Copayments, as payment in full for services rendered.
Renewal Date - The date on which the Group Contract renews. Also known as “Anniversary Date”.
Schedule of Benefits - Attached summary of Covered Services and Copayments, Waiting Periods and
maximums applicable to benefits, services, supplies or charges payable under the Plan.
Schedule of Exclusions and Limitations – Attached list of Exclusions and Limitations applicable to
benefits, services, supplies or charges under the Plan.
Service Area – The state of Maryland.
Special Enrollment Period - The period of time outside Your Group’s open enrollment period during which
individuals eligible as Certificate Holders or Dependents who experience certain qualifying events may enroll
in this Group Contract.
Specialty Care Dentist - A specialized Dentist who is board eligible, board qualified, or board certified in one
of the specialty areas of periodontics, oral surgery, orthodontics, endodontics and pediatrics and who has
executed a contract with Us to accept negotiated fees plus any applicable Copayments, as payment in full for
Covered Services provided to Members.
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Spouse – The Certificate Holder’s partner by marriage or by any union between two adults that is recognized
by law in Maryland.
Termination Date - The date on which the dental coverage ends for a Member or on which the Group
Contract terminates.
We, Our or Us - The Company, its affiliate or an organization with which it contracts for a provider network
and/or to perform certain functions to administer this Group Contract.
ELIGIBILITY AND ENROLLMENT -- WHEN COVERAGE BEGINS
New Enrollment
In order to be a Member, You must meet the eligibility requirements of Your Group and this Group Contract.
If You are enrolling through Maryland Health Connection, You must meet any additional eligibility
requirements of Maryland Health Connection and provide enrollment information to it. We must receive
enrollment information for the Certificate Holder, enrolled Dependents, and Contractholder. Provided that
We receive applicable Premium, coverage will begin on the date specified in the enrollment information We
receive. Your Group will inform Certificate Holders of its eligibility requirements.
If You have already satisfied all eligibility requirements on the Group Contract Effective Date and Your
enrollment information and applicable Premium is supplied to Us, Your coverage will begin on the Group
Contract Effective Date.
If You are not eligible to be a Member on the Group Contract Effective Date, You must supply the required
enrollment information on Yourself and any eligible Dependents, as specified in the Definitions section, within
thirty-one (31) days of the date You meet the applicable eligibility requirements.
Coverage for Members enrolling after the Group Contract Effective Date will begin on the date specified in
the enrollment information supplied to Us provided Premium is paid.
The Company is not liable to pay benefits for any services started prior to a Member’s Effective Date of
coverage. Multi-visit procedures are considered “started” when the teeth are irrevocably altered. For
example, for crowns, bridges and dentures, the procedure is started when the teeth are prepared and
impressions are taken. For root canals, the procedure is started when the tooth is opened and pulp is
removed. Procedures started prior to the Member’s Effective Date are the liability of the Member or a prior
insurance carrier.
Special Enrollment Periods - Enrollment Changes
After Your Effective Date, You can change Your enrollment during Your Group’s open enrollment period.
There are also Special Enrollment Periods when an employee under a group contract may add or remove
Dependents or himself. These life change events include:
birth of a child or grandchild;
adoption of a child;
court order of placement or custody of a child;
change in student status for a child or grandchild;
loss of other coverage;
marriage or other lawful union between two adults.
If You enrolled, or are eligible through Your Group, to enroll a new Dependent or Yourself as a result of one
of these events, You must supply the required enrollment change information within thirty-one (31) days of
the date of the life change event. The Dependent must meet the definition of Dependent applicable to this
Group Contract.
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The Certificate Holder may also add or remove Dependents or change Plans for the reasons defined by and
during the timeframes specified by applicable law or regulation.
If You enrolled through Maryland Health Connection, or need to enroll due to a permitted life change event,
there are additional life change events that may permit You to add or remove Dependents or Yourself, or
change Plans. In addition to the life change events noted above, the additional Special Enrollment Period
events that apply to participation through Maryland Health Connection include changes in:
state of residence or access to a new QHP because of a permanent move;
incarceration status;
Enrollment or non-enrollment was unintentional, inadvertent or erroneous and the result of an
error by the Exchange or HHS;
A qualified plan substantially violated a material provision of its contract with the individual;
Individuals who are Indians may change dental plans on the Exchange once per month;
Individual or dependent demonstrates to the Exchange in accordance with HHS guidelines, that
the individual meets other exceptional circumstances;
Loss of eligibility for coverage under a Medicaid plan or CHIP plan, or an individual becomes
eligible for assistance, with respect to coverage under the Maryland Health Connection, under
such Medicaid or CHIP plan.
The Special Enrollment Period during which You must supply the required enrollment change information to
Maryland Health Connection is thirty (30) days from the date of the life change event. You must supply the
required enrollment change information to the Authorized Entity within sixty (60) days from the date of a loss
of eligibility for coverage under a Medicaid or CHIP plan. The Dependent must meet the definition of
Dependent applicable to this Group Contract.
Except for newly born or adoptive children, coverage for the new Dependent will begin on the the date
specified in the enrollment information provided to Us or on the date dictated by Maryland Health
Connection, in accordance with Federal Guidelines as long as the Premium is paid.
Newly born children and grandchildren of a Member will be considered enrolled from the moment of birth.
Adoptive children will be considered enrolled from the date of adoption or placement, except for those
adopted or placed within thirty-one (31) days of birth who will be considered enrolled Dependents from the
moment of birth. A minor for whom guardianship is granted by court or testamentary appointment shall be
considered enrolled from the date of appointment. In order for coverage of newly born or adoptive children
to continue beyond the first thirty-one (31) day period, if additional premium is required to cover a newly
enrolled dependent child, the child’s enrollment information must be provided to Us and the required
Premium must be paid within the thirty-one (31) day period. If you enrolled for pediatric coverage certified
by the Maryland Health Connection, once three children are covered under the plan, no additional
premiums are required for subsequent children, and We will not terminate coverage after thirty-one (31)
days at this point, even if the enrollment information is not provided within the thirty-one (31) day time
period.
A child or grandchild of a Certificate Holder will not be denied the status of Dependent on the grounds that
the child or grandchild: (a) was born out of wedlock; (b) is not claimed as a dependent on the Certificate
Holder’s federal income tax return; (c) does not reside with the Certificate Holder or in the Company’s
Service Area.
For an enrolled Dependent child who is a full-time student, proof of his/her student status and reliance on
You for support must be furnished to Us within thirty (30) days after he/she reaches the limiting age shown
in the definition of Dependent. The Company will send notification to the Member at least ninety (90) days
prior to the date the dependent child attains the limiting age. Such evidence will be requested annually
thereafter until the Dependent reaches the limiting age for students and his/her coverage ends.
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For an enrolled Dependent child who is mentally or physically incapacitated, proof of his/her reliance on
You for support due to his/her condition must be supplied to Us within thirty (30) days after said
Dependent attains the limiting age shown in the definition of Dependent. The Company will send
notification to the Member at least ninety (90) days prior to the date the dependent child attains the limiting
age. Such evidence will be requested based on information provided by the Member’s physician but no
more frequently than annually.
Dependent coverage may only be terminated when certain life change events occur including death, divorce
or dissolution of the union or domestic partnership, reaching the limiting age or during open enrollment
periods or when otherwise permitted by applicable law or regulation intended to implement the Federal
Affordable Care Act or specified in any applicable Late Entrant Rider to the Certificate of Coverage.
Late Enrollment
If You or Your Dependents are not enrolled within thirty-one (31) days of initial eligibility or during the Special
Enrollment Period specified for a life change event, You or Your Dependents cannot enroll until the next
Special Enrollment Period or open enrollment period conducted for Your Group unless otherwise permitted
by applicable law or regulation intended to implement the federal Affordable Care Act. If You are required by
court order to provide coverage for a Dependent child, You will be permitted to enroll the Dependent child
without regard to enrollment season restrictions.
Voluntary Disenrollment
If You chose to drop Your coverage or Your Dependents’ coverage under the Plan at any time during the
contract year other than at open enrollment or during open enrollment, you will not be permitted to enroll
Yourself or Your dependents at a later time unless You supply proof of loss of coverage under another dental
plan. The loss of coverage must be due to a valid life change event. If you supply such proof, you will be
permitted to re-enroll.
HOW THE DENTAL PLAN WORKS
Choice of Provider at Enrollment
You must select a Primary Dental Office for Yourself and Your Dependents. Each Member may select a
different Primary Dental Office. If You or Your Dependents do not select a Primary Dental Office, You will be
assigned to one in a location convenient to Your home zip code. The Primary Dental Office(s) will be notified
of Your selection or assignment.
To find a Primary Dental Office, visit Our website or call Us at the toll-free number in the Introduction
section of this Certificate or on Your ID card.
Once enrolled, You will receive an ID Card or other notification indicating Your contract ID number, plan
number, Group number and the names of the Primary Dental Offices You and Your Dependents selected
or that were assigned by Us. Present Your ID card to Your dental office or give the office Your ID number,
Plan number and Group number. If Your Dentist has questions about Your eligibility or benefits, instruct
the office to call Us or visit Our website.
Changing Primary Dental Offices
You or Your Dependents may request to change Primary Dental Offices at any time. Simply call our
Customer Service center toll-free at the number in the Introduction section of this Certificate or visit Our
website. You will be informed of the effective date of the transfer, and the newly selected office will also
be notified. You must request the transfer prior to seeking services from the new Primary Dental Office.
Any dental procedures in progress must be completed before the transfer.
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If You or Your Dependents are enrolled in a Primary Dental Office that stops participating in the Plan, We will
notify You and assist You or Your Dependents with selecting another Primary Dental Office.
Continuity of Care
If Your Primary Care Dentist or Specialty Care Dentist no longer participates with the Plan, coverage for
completion of a dental procedure will be extended for a period of at least ninety (90) days from the date of the
notice of a Primary Dental Office’s or Specialty Care Dentist’s termination from the Plan for reasons
unrelated to fraud, patient abuse, incompetency, or loss of licensure status. The Primary Dental Office or
Specialty Care Dentist shall render dental services to any of the Plan’s Members who:
were receiving dental services from the In-Network Dentist prior to the notice of termination; and
after receiving notice of the In-Network Dentist’s termination, request to continue receiving dental
services from that Dentist.
Coordination of Care and Referrals
The Primary Dental Office assigned to You or Your Dependents must provide or coordinate all Covered
Services. When specialty care such as surgical treatment of the gums or a root canal is needed, the Primary
Dentist may perform the procedure or give You a written referral to a Specialty Care Dentist. All benefits
must be provided by In-Network Dentists, with the exception of Dental Emergencies or if a Primary Dentist or
Specialty Care Dentist is not available in Your area, Standing Referrals, or Out-of-Network referrals as
described in this section. See the next sections for details on these situations.
When specialty care such as surgical treatment of the gums or a root canal is needed, the Primary Dentist
may perform the procedure or refer You to a specialist. All referrals must be made to a participating Specialty
Care Dentist. Your Primary Dentist will give You a written referral to take to the Specialty Care Dentist. The
Specialty Care Dentist will perform the treatment and submit a claim and the referral to Us for processing.
The claim will be denied if the written referral is not submitted. Referral is limited to endodontic, orthodontic,
periodontic, oral surgery, and pedodontic Specialty Care Dentists.
Standing Referral Guidelines
For standing referrals, You are not required to see Your Primary Dental Office prior to appointments with the
Specialty Care Dentist. A standing referral for Your Covered Services is made under a written treatment plan
by the Specialty Care Dentist and the Primary Dental Office.
The Company will allow a standing referral to a Specialty Care Dentist when all of the following conditions are
met:
Your Primary Dental Office (PDO) of the Member determines, in consultation with the Specialty Care
Dentist, that the Member needs continuing care from the Specialty Care Dentist;
You have a condition or disease that is life threatening, degenerative, chronic, or disabling that
requires specialized care;
the Specialty Care Dentist has expertise in treating such condition and is part of the Company’s
provider network.
The Primary Dental Office must complete the Specialty Referral/Claim Form specifying the services referred
to the Specialty Care Dentist. The referral should explain why the standing referral is necessary.
You should take the Specialty Referral/Claim Form to the Specialty Care Dentist at Your first appointment.
The Specialty Care Dentist provides treatment at each appointment and submits a copy of the Specialty
Referral/Claim Form to Us.
Out-of-Network Referral Guidelines
The Company will allow You a referral to an Out-of-Network specialist if all of the following conditions are
met:
You are diagnosed with a condition or disease that requires specialized care;
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The Company does not have a Specialty Care Dentist in its panel with the training and expertise to
treat the condition or disease;
The Company cannot provide reasonable access to a Specialty Care Dentist with the
professional training and expertise to treat or provide dental services for the condition or disease
without unreasonable delay or travel.
You are responsible only for the applicable copayment, as indicated on the Schedule of Benefits.
The Primary Dental Office (PDO) must complete the Specialty Referral/Claim Form specifying the services
referred to the Out-of-Network specialist. The referral will explain the need for specialized care and why an
Out-of-Network specialist is needed. The Primary Dental Office should contact Customer Service to notify
the Company of the Out-of-Network referral and to receive the authorization number.
You should take the Specialty Referral/Claim Form to the Out-of-Network specialist. The Out-of-Network
specialist provides treatment and submits the Specialty Referral/Claim Form to the Company.
Should You have any questions concerning Your coverage, eligibility or a specific claim, contact Us at the
address and telephone number in the Introduction section of this Certificate or log onto Our website.
If a plan dentist refers You to a specialist who is not a plan dentist for covered dental services under the
dental benefit contract, We shall be responsible for payment of the specialist's charges to the extent the
charges exceed the copayment specified in the dental benefit contract.
Dental Emergencies
When immediate dental treatment is required as a result of a Dental Emergency and You are more than fifty
(50) miles from Your home when the Dental Emergency occurs, contact Your Primary Dental Office or go to
a conveniently located general Dentist. Ask the dental office to call Our Customer Service unit to verify
coverage. Be sure to get an itemized bill from the dental office to submit to Us. The Plan will cover certain
diagnostic and therapeutic procedures in accordance with the Schedule of Exclusions and Limitations. Your
out-of-pocket cost will be limited to any applicable Copayment on the Schedule of Benefits.
Out-of-Network Care
When a Specialty Care Dentist is not available within a thirty (30) mile radius of Your home, We may
authorize treatment by an Out-of-Network Dentist. Call Our Customer Service unit at the telephone number
listed in the Introduction section of this Certificate. The unit will assist You by arranging a visit to an Out-of-
Network Dentist. You are liable for only the applicable Copayment, as indicated in Your Schedule of Benefits,
as long as the procedure is a Covered Service.
In addition, a Standing Referral and Out-of-Network referral, as described in the Coordination of Care and
Referrals section, will provide You with a benefit for Out-of-Network care.
BENEFITS
Covered Services
Benefits and any applicable Copayments, Deductibles, Annual Maximums, Lifetime Maximums, Out-of-
Pocket Maximums and Waiting Periods are shown on the attached Schedule of Benefits. Certain
Limitations may also be shown on the Schedule of Benefits. Services shown on the Schedule of Benefits
as covered are subject to frequency or age Limitations detailed on the attached Schedule of Exclusions
and Limitations.
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Only services, supplies and procedures listed on the Schedule of Benefits are Covered Services. For
items not listed (not covered), You are responsible for the full fee charged by the Dentist. No benefits will
be paid for services, supplies or procedures detailed under the Exclusions on the Schedule of Exclusions
and Limitations.
Exclusions
No benefits will be provided for services, supplies or charges detailed as Exclusions on the Schedule of
Exclusions and Limitations. Services shown on the Schedule of Benefits as covered may also be subject
to frequency or age Limitations as detailed on the attached Schedule of Exclusions and Limitations.
Copayments and Other Charges
In order to keep the Plan affordable for You and Your Group, the Plan includes certain cost-sharing
features. First, not all dental procedures are covered. If the procedure is not listed on the Schedule of
Benefits, it is not covered. You will be responsible to pay Your Dentist the full charge for uncovered
services.
Certain procedures listed on the Schedule of Benefits require You to pay a Copayment. Copayments are
listed in the right-hand column on the Schedule. You are responsible to pay the Copayments at the time of
service unless You have made other arrangements with the Primary Dental Office or Specialty Care
Dentist. Copayments are the same whether the service is provided by Your Primary Dentist or by a
Specialty Care Dentist through referral. Services listed on the Schedule of Benefits with a “0” or “N/C” in
the column require no Copayment from You.
Services listed on the Schedule of Benefits are also subject to Exclusions and Limitations. Be sure to
review both the Schedule of Benefits and the Schedule of Exclusions and Limitations attached to this
Certificate. Services not listed on the Schedule of Benefits, Exclusions, or those beyond stated Limitations
are not covered and are Your responsibility.
Other Charges for Alternate Treatment
Frequently, several alternate methods exist to treat a dental condition. For example, a tooth can be restored
with a crown or a filling, and missing teeth can be replaced either with a fixed bridge or a partial denture. We
will make payment based upon the allowance for the less expensive procedure, provided that the less
expensive procedure meets accepted standards of dental treatment. Our decision does not commit You to
the less expensive procedure. However, if You and the Dentist choose the more expensive procedure, You
are responsible for the additional charges beyond those paid or allowed by the Company.
Payment of Benefits
We will pay covered benefits directly to Your assigned Primary Dental Office or the Specialty Care Dentist.
Payment is based on rates contracted with In-Network Dentists. All contracts between Us and the In-Network
Dentists state that under no circumstances will the Member be liable to any Dentists for any sum owed by Us
to the Dentists. In any instance We fail or refuse to pay the Dentist, such dispute is solely between the
Dentist and Us, and, other than Copayments, You are not liable for any monies We fail or refuse to pay.
The Company’s compensation to Dentists who offer dental health care services to You may be based on a
variety of payment mechanisms such as fee-for-service payments, salary, or capitation. Bonuses may be
used with these various types of payment methods. For additional information about Our methods of paying
Dentists, or the method(s) that apply to your Dentist, please call Us at the toll-free number in the introduction
section of this Certificate.
If, during the term of this Contract, none of the In-Network Dentists can render necessary care and treatment
to You due to circumstances not reasonably within Our control, such as complete or partial destruction of
facilities, war, riot, civil insurrection, labor disputes, or the disability of a significant number of the In-Network
Dentists, then You may seek treatment from a licensed Out-of-Network Dentist of You choice. We will pay
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You for the expenses incurred for the dental services with the following limitations: We will pay You for the
services which are listed in the Copayment schedule as No Charge, to the extent that such fees are
reasonable and customary for Dentists in the same geographic area; We will also pay You for those services
listed in the Contract for which there is a Copayment, to the extent that the reasonable and customary fees
for such services exceed the Copayment for such services as set forth in the Contract. You may be required
to give written proof of loss (file a claim). The Company agrees to be subject to the jurisdiction of the
Maryland Insurance Commissioner in any dispute about the possibility of providing services by In-Network
Dentists.
Coordination of Benefits (COB)
If You or Your Dependents are covered by any other dental plan and receive a service covered by this Plan
and the other dental plan, benefits will be coordinated. This means that one plan will be primary and
determine its benefits before those of the other plan and without considering the other plan's benefits. The
other plan will be secondary and determine its benefits after the primary plan. The secondary plan’s benefits
may be reduced because of the primary plan's payment. Each plan will provide only that portion of its benefit
that is required to cover expenses. This prevents duplicate payments and overpayments. Upon
determination of primary or secondary liability, this Plan will determine payment.
1. The following words and phrases regarding the Coordination of Benefits ("COB") provision are defined as
set forth below:
A) Allowable Amount is the necessary, reasonable and customary items of expense, when the care is
covered at least in part by one or more Plans covering the Member for whom the claim is made.
B) Claim Determination Period means a benefit year. However, it does not include any part of a year
during which a person has no coverage under this Plan.
C) Other Dental Plan is any form of coverage which is separate from this Plan with which coordination
is allowed. Other Dental Plan will be any of the following which provides dental benefits, or
services, for the following: Group insurance or group type coverage, whether insured or uninsured. It
also includes coverage other than school accident type coverage (including grammar, high school
and college student coverages) for accidents only, including athletic injury, either on a twenty-four
(24) hour basis or on a "to and from school basis," or group or group type hospital indemnity benefits
of $100 per day or less.
D) Primary Plan is the plan which determines its benefits first and without considering the other plan's
benefits. A plan that does not include a COB provision may not take the benefits of another plan into
account when it determines its benefits.
E) Secondary Plan is the plan which determines its benefits after those of the other plan (Primary
Plan). Benefits may be reduced because of the other plan's (Primary Plan) benefits.
F) Plan means this document including all schedules and all riders thereto, providing dental care
benefits to which this COB provision applies and which may be reduced as a result of the benefits of
other dental plans.
2. The fair value of services provided by the Company will be considered to be the amount of benefits paid
by the Company. The Company will be fully discharged from liability to the extent of such payment under
this provision.
3. In order to determine which plan is primary, this Plan will use the following rules.
A) If the other plan does not have a provision similar to this one, then that plan will be primary.
B) If both plans have COB provisions, the plan covering the Member as a primary insured is determined
before those of the plan which covers the person as a Dependent; however if the Covered Person is
a Medicare Beneficiary, then Medicare is secondary to the plan covering the person as a
dependent and primary to the plan covering the person as other than a dependent.
C) Dependent Child/Parents Who are Married or are Living Together -- The rules for the order of
benefits for a Dependent child when the parents are married or are living together are:
1) The benefits of the plan of the parent whose birthday falls earlier in a year are determined
before those of the plan of the parent whose birthday falls later in that year;
13
MD9805 (02/13)
2) If both parents have the same birthday, the benefits of the plan which covered the parent
longer are determined before those of the plan which covered the other parent for a shorter
period of time;
3) The word "birthday" refers only to month and day in a calendar year, not the year in which
the person was born;
4) If the other plan does not follow the birthday rule, but instead has a rule based upon the
gender of the parent; and if, as a result, the plans do not agree on the order of benefits, the
rule based upon the gender of the parent will determine the order of benefits.
D) Dependent Child/Separated or Divorced Parents or Parents Who Are no Longer Living Together --
If two or more plans cover a person as Dependent child of divorced or separated parents, or
parents who are no longer living together, benefits for the child are determined in this order:
1) First, the plan of the parent with custody of the child.
2) Second, the plan of the spouse of the parent with the custody of the child; and
3) Third, the plan of the parent not having custody of the child.
4) Finally the plan of the spouse of the parent not having custody of the child.
5) If the specific terms of a court decree state that one of the parents is responsible for the
dental care expenses of the child, and the entity obligated to pay or provide the benefits of
the plan of that parent has actual knowledge of those terms, the benefits of that plan are
determined first. The plan of the other parent will be the Secondary Plan.
6) If the specific terms of the court decree state that the parents will share joint custody, without
stating that one of the parents is responsible for the dental care expenses of the child, the
plans covering the child will follow the order of benefit determination rules outlined in Section
3-C) above, titled Dependent Child/Parents Not Separated or Divorced.
E) Active/Inactive Member
1) The plan that covers a person as an active employee that is, an employee who is neither
laid off nor retired or as a dependent of an active employee is the primary plan. The plan
covering that same person as a retired or laid-off employee or as a dependent of a retired or
laid-off employee is the secondary plan.
2) If the other plan does not have this rule, and as a result, the plans do not agree on the
order of benefits, this rule is ignored.
3) This rule does not apply if the rule in Paragraph (3.B) can determine the order of benefits.
F) The plan covering an individual as a COBRA or state continuee will be secondary to a plan
covering that individual as a Member or a Dependent.
G) If none of these rules apply, then the contract which has continuously covered the Member for a
longer period of time will be primary and the plan that covered the person for the shorter period of
time is secondary. In determining the amount to be paid by the secondary plan on a claim,
should the plan wish to coordinate benefits, the secondary plan shall calculate the benefits it
would have paid on the claim in the absence of other health care coverage and apply that
calculated amount to any allowable expense under its plan that is unpaid by the primary plan.
The secondary plan may reduce its payment by the amount so that, when combined with the
amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do
not exceed 100 percent of the total allowable expense for that claim. In addition, the secondary
plan shall credit to its plan deductible any amounts it would have credited to its deductible in
the absence of other health care coverage.
H) 1. If the preceding rules do not determine the order of benefits, the plan that covered the person
for the longer period of time is the primary plan and the plan that covered the person for the shorter
period of time is the secondary plan.
2. To determine the length of time a person has been covered under a plan, two successive plans
shall be treated as one if the covered person was eligible under the second plan within twenty-four
(24) hours after coverage under the first plan ended.
3. The start of a new plan does not include: A change in the amount or scope of a plan’s benefits; A
change in the entity that pays, provides or administers the plan’s benefits; or A change from one type
of plan to another, such as, from a single employer plan to a multiple employer plan.
4. The person’s length of time covered under a plan is measured from the person’s first date of
coverage under that plan. If that date is not readily available for a group plan, the date the person first
became a member of the group shall be used as the date from which to determine the length of time
the person’s coverage under the present plan has been in force.
14
MD9805 (02/13)
4. Right to Receive and Release Needed Information -- Certain facts are needed to apply these COB rules.
The Company has the right to decide which facts it needs. It may get needed facts from or give them to
any other organization or person. Any health information furnished to a third party will be released in
accordance with state and federal law. Each person claiming benefits under This Plan must give any
facts needed to pay the claim.
5. Facility of Payment -- A payment made under another plan may include an amount which should have
been paid under this Plan. If it does, the Company may pay the amount to the organization which made
that payment. That amount will then be treated as though it were a benefit paid under This Plan, and the
Company will not pay that amount again. The term "payment made" includes providing benefits in the
form of services, in which case "payment made" means reasonable cash value of the services prepaid
by the Company.
6. Right of Recovery -- If the payment made by the Company is more than it should have paid under this
COB provision, the Company may recover the excess from one or more of the following: (1) persons it
has paid or for whom it has paid; or (2) insurance companies; or (3) other organization. Members are
required to assist the Company to implement this section.
Workers’ Compensation
When a Member is eligible for Workers’ Compensation benefits through employment, the cost of dental
treatment for an injury which arises out of and in the course of Member’s employment is not a covered
benefit under this Plan. Therefore, if the Company pays benefits which are covered by a Workers’
Compensation Contract, the Company has the right to obtain reimbursement for those benefits paid. The
Member must provide any assistance necessary, including furnishing information and signing necessary
documents, for the Company to receive the reimbursement.
Review of a Benefit Determination
If You are not satisfied with the Plan’s benefit, please contact Our Customer Service Department at the toll-
free telephone number in the Introduction section of this Certificate or on Your ID card. If, after speaking with
a Customer Service representative, You are still dissatisfied, refer to the Appeal Procedure Addendum
attached to this Certificate for further steps You can take regarding Your claim.
TERMINATION -- WHEN COVERAGE ENDS
Member’s coverage will end at 12:00 AM EST notice from:
On the date You lose no longer meet Your Group’s eligibility requirements; or
On the date Premium payment ceases for You; or
On the date You no longer meet the eligibility requirements for a Dependent, as defined in the
Definitions section of this Certificate.
On the date the Certificate Holder’s coverage ends or the Certificate Holder is no longer eligible to enroll
his/her Dependents, Dependent coverage will end. If the Group Contract is cancelled, Certificate Holder and
Dependent coverage will end on the Group Contract Termination Date. The Primary Dental Office or
Specialty Care Dentist will notify You of Your Group Contract’s termination if the In-Network Dentist is aware
that the Group Contract has terminated. The In-Network Dentist will inform You of the charge for any
scheduled dental services before performing the dental services.
15
MD9805 (02/13)
If the Contractholder fails to pay Premium, Coverage will remain in effect during the Grace Period. If the
Premium is not received within the Grace Period, coverage will be immediately cancelled on the first day
following the expiration of the Grace Period. The Contractholder is liable for Premium accrued during the
Grace Period.
We are not liable to pay any benefits for services that are started after Your Termination Date or after the
Group Contract Termination Date. However, coverage for completion of a dental procedure requiring two (2)
or more visits on separate days will be extended for a period of ninety (90) days after the Termination Date in
order for the procedure to be finished. The procedure must be started prior to the Termination Date. The
procedure is considered “started” when the teeth are irrevocably altered. For example, for crowns, bridges
and dentures, the procedure is started when the teeth are prepared and impressions are taken. For root
canals, the procedure is started when the tooth is opened and pulp is removed. This extension does not
apply if the Group Contract terminates for failure to pay Premium.
Services for orthodontic treatment will continue for sixty (60) days after the Termination Date if the
orthodontist has agreed to or is receiving monthly payments; or until the later of sixty (60) days after the
Termination Date or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving
quarterly payments. This extension of orthodontic payment does not apply if coverage was terminated due to
the individual’s failure to pay Premium, the individual’s fraud, or if coverage without interruption of benefits is
provided by another health plan and the cost is less than or equal to the cost of coverage for the individual
during the extension.
CONTINUATION COVERAGE
Federal or state law may require certain employers that meet certain criteria to offer continuation coverage
to Members for a specified period of time upon termination of employment or reduction of work hours for
any reason other than gross misconduct. Certain employers including churches and small businesses are
not required to offer this coverage. Contact Your Group to find out if this applies to You. Your Group will
advise You of Your rights to continuation coverage and the cost. If this requirement does apply, You must
elect to continue coverage within sixty (60) days from Your qualifying event or notification of rights by Your
Group, whichever is later. Dependents may have separate election rights, or You may elect to continue
coverage for them. You must pay the required premium for continuation coverage directly to Your Group.
The Company is not responsible for determining who is eligible for continuation coverage.
CONVERSION OF COVERAGE
The Company allows You and Your Dependents to continue Your coverage under a Conversion Certificate of
Coverage without evidence of insurability. You are not eligible for a Conversion Certificate of Coverage if
You or Your Dependent(s) coverage under the Group Contract ends because: (a) You fail to pay any
required contribution toward the cost of the dental benefits; or (b) the Company terminates Your coverage
due to Member fraud in the use of dental services or facilities; or (c) You change Your residence to an area
outside the State of Maryland. To convert coverage, You or Your Dependent(s) must apply in writing and pay
the first three (3) month’s Premium to the Company within thirty (30) days after Your Termination Date.
Coverage under the Conversion Certificate of Coverage becomes effective on Your Termination Date for this
Group Contract.
GENERAL PROVISIONS
This Certificate includes and incorporates any and all riders, endorsements, addenda, and schedules and
together with the Group Contract represents the entire agreement between the parties with respect to the
dental Plan. The failure of any section or subsection of this Certificate shall not affect the validity, legality and
enforceability of the remaining sections.
This Certificate will be construed for all purposes as a legal document and will be interpreted and enforced in
accordance with pertinent laws and regulations of the State of Maryland.
16
MD9805 (02/13)
Privacy and Confidentiality of Dental Records
We do not disclose claim or eligibility records except as allowed or required by law and then in accordance
with federal and state law. We maintain physical, electronic, and procedural safeguards to guard claims and
eligibility information from unauthorized access, use, and disclosure.
A statement describing Our policies and procedures for preserving the confidentiality of dental records is
available and will be furnished to You upon request.
Rights of Company to Change Plan
Except as otherwise herein provided, this Certificate may be amended, changed or modified only in writing
and thereafter attached hereto as part of this Certificate.
StMD DHMO Eligibility 0114
UNITED CONCORDIA
ENDORSEMENT
TO THE
DENTAL PLAN CERTIFICATE OF COVERAGE (“CERTIFICATE”)
This Endorsement is effective on the Effective Date as stated in the Group Contract and attached to and
made part of the Group Contract and the Certificate.
Eligibility and Enrollment
The Eligibility and Enrollment – When Coverage Begins section of the Certificate is hereby replaced in
its entirety with the following:
ELIGIBILITY AND ENROLLMENT -- WHEN COVERAGE BEGINS
New Enrollment
In order to be a Member, You must meet the eligibility requirements of Your Group and this Group
Contract. We must receive enrollment information for the Certificate Holder, enrolled Dependents, and
Contractholder. Provided that We receive applicable Premium, coverage will begin on the date
specified in the enrollment information We receive. Your Group will inform Certificate Holders of its
eligibility requirements.
If You have already satisfied all eligibility requirements on the Group Contract Effective Date and Your
enrollment information and applicable Premium is supplied to Us, Your coverage will begin on the
Group Contract Effective Date.
If You are not eligible to be a Member on the Group Contract Effective Date, You must supply the
required enrollment information on Yourself and any eligible Dependents, as specified in the Definitions
section, within sixty (60) days of the date You meet the applicable eligibility requirements.
Coverage for Members enrolling after the Group Contract Effective Date will begin on the date specified
in the enrollment information supplied to Us provided Premium is paid.
The Company is not liable to pay benefits for any services started prior to a Member’s Effective Date of
coverage. Multi-visit procedures are considered “started” when the teeth are irrevocably altered. For
example, for crowns, bridges and dentures, the procedure is started when the teeth are prepared and
impressions are taken. For root canals, the procedure is started when the tooth is opened and pulp is
removed. Procedures started prior to the Member’s Effective Date are the liability of the Member or a
prior insurance carrier.
Special Enrollment Periods - Enrollment Changes
After Your Effective Date, You can change Your enrollment during Your Group’s open enrollment
period. There are also Special Enrollment Periods when the Certificate Holder may add or remove
Dependents or himself. These life change events include:
birth of a child or grandchild;
adoption of a child;
court order of placement or custody of a child;
loss of other coverage;
StMD DHMO Eligibility 0114
marriage or other lawful union between two adults. .
If You enrolled, or are eligible through Your Group, to enroll a new Dependent or Yourself as a result of
one of these events, You must supply the required enrollment change information within sixty (60) days
of the date of the life change event. The Dependent must meet the definition of Dependent applicable to
this Group Contract.
The Certificate Holder may also add or remove Dependents or change Plans for the reasons defined by
and during the timeframes specified by applicable law or regulation.
Except for newly born or adoptive children, coverage for the new Dependent will begin on the the
date specified in the enrollment information provided to Us as long as the Premium is paid.
Newly born children and grandchildren of a Member will be considered enrolled from the moment of
birth. Adoptive children will be considered enrolled from the date of adoption or placement, except for
those adopted or placed within sixty (60) days of birth who will be considered enrolled Dependents
from the moment of birth. A minor for whom guardianship is granted by court or testamentary
appointment shall be considered enrolled from the date of appointment. In order for coverage of
newly born or adoptive children to continue beyond the first sixty (60) day period, if additional
premium is required to cover a newly enrolled dependent child, the child’s enrollment information
must be provided to Us and the required Premium must be paid within the sixty (60) day period.
A child or grandchild of a Certificate Holder will not be denied the status of Dependent on the grounds
that the child or grandchild: (a) was born out of wedlock; (b) is not claimed as a dependent on the
Certificate Holder’s federal income tax return; (c) does not reside with the Certificate Holder or in the
Company’s Service Area.
For an enrolled Dependent child who is mentally or physically incapacitated, proof of his/her reliance
on You for support due to his/her condition must be supplied to Us within sixty (60) days after said
Dependent attains the limiting age shown in the definition of Dependent. The Company will send
notification to the Member at least ninety (90) days prior to the date the dependent child attains the
limiting age. Such evidence will be requested based on information provided by the Member’s
physician but no more frequently than annually.
Dependent coverage may only be terminated when certain life change events occur including death,
divorce or dissolution of the union, reaching the limiting age or during open enrollment periods or
specified in any applicable Late Entrant Rider to the Certificate of Coverage.
Late Enrollment
If You or Your Dependents are not enrolled within sixty (60) days of initial eligibility or during the Special
Enrollment Period specified for a life change event, You or Your Dependents cannot enroll until the next
Special Enrollment Period or open enrollment period conducted for Your Group. If You are required by
court order to provide coverage for a Dependent child, You will be permitted to enroll the Dependent
child without regard to enrollment season restrictions.
StMD DHMO Eligibility 0114
General
Except where specifically changed by this Endorsement, all of the terms and conditions of Your Plan’s
Certificate of Insurance continue to apply. In the event of a conflict between the provisions in this
Endorsement and the Certificate of Insurance, this Endorsement shall control.
United Concordia Dental Plans, Inc.
__________________________________________
Authorized Officer
MDDHMO Appeal-ADD (05/13)
APPEAL PROCEDURE
This Addendum is effective on the Effective Date stated in the Group Contract or Individual Conversion Dental Plan
Contract. It is attached to and made part of the Certificate.
The following contains important information about how to file an Appeal. If You are dissatisfied with Our benefit
determination on a claim, You may Appeal Our decision by following the steps outlined in this procedure. We will resolve
Your Appeal in a thorough, appropriate, and timely manner. You, Your Authorized Representative, or Your Health Care
Provider may submit written comments, documents, records and other information relating to claims or Appeals. You may
call Us at (888) 638-3384 or write to Us at P.O. Box 69420, Harrisburg PA 17106-9420. We will provide a review that
takes into account all information submitted whether or not it was considered with its first determination on the claim. Any
notifications by Us required under these procedures will be supplied to You, Your Authorized Representative, or Your
Health Care Provider.
Definitions
The following terms when used in this procedure have the meanings shown below.
“Appeal " is a protest filed by You, Your Authorized Representative or a Health Care Provider with Us under Our internal
appeal process regarding a Coverage Decision.
“Appeal Decision" is a final determination by Us that arises from an Appeal filed with Us under Our Appeal procedure
regarding a Coverage Decision.
“Authorized Representative” is a person granted authority to act on Your behalf regarding a claim for benefit or an Appeal
of a Coverage Decision. An assignment of benefits is not a grant of authority to act on Your behalf in pursuing a Coverage
Decision.
“Claim for Benefits” is a request for a plan benefit or benefits by You in accordance with the Plan’s reasonable procedure
for filing benefit claims, including Pre-service and Post-service Claims.
“Compelling Reason” means that a delay in receiving the health care service could result in loss of life, serious impairment
to a bodily function, or serious dysfunction of a bodily organ or part, or the Member remaining seriously mentally ill with
symptoms that cause the member to be in danger to self or others.
“Complaint" is a protest filed with the Commissioner involving a Coverage Decision.
“Coverage Decisions” is:
1. The initial determination by Us resulting in non-coverage of a dental care service;
2. The determination by Us that You are not eligible for coverage.
3. A determination by Us that results in a rescission of coverage.
The Company does not make utilization review determinations based on dental necessity or appropriateness. A
Coverage Decision is not an Adverse Decision.
“Health Care Provider” is an individual who is licensed under the Health Occupations Article to provide health care
services in the ordinary course of business or practices of a profession and is a treating provider of the Member or a
Hospital.
“Hospital” means an institution that: has a group of at least five (5) physicians who are organized as a medical staff for the
institution; maintains facilities to provide, under the supervision of the medical staff, diagnostic and treatment services for
two (2) or more unrelated individuals; and admits or retains the individuals for overnight care.
“Pre-service Claim” is a Claim for Benefits under the Plan when the terms of the Plan condition receipt of the benefit, in
whole or in part, on approval of the benefit in advance of obtaining dental care.
MDDHMO Appeal-ADD (05/13)
“Post-service Claim” (“Claim”) is any Claim for Benefits under a group health plan that is not a Pre-service Claim.
PROCEDURE FOR PRE-SERVICE CLAIM
You, Your Health Care Provider, or Your Authorized Representative have 180 days from the date You or Your Authorized
Representative received notice of the Coverage Decision to appeal the decision. To file an appeal, call the toll-free
telephone number listed in Your Certificate of Coverage or on Your ID card.
The dentist advisor involved in the appeal will be different from and not a subordinate of the dentist advisor involved in the
adverse determination on initial Claim for Benefits. We will provide You, Your Health Care Provider, or Your Authorized
Representative with written or electronic notice of Our appeal decision within 30 days of the request to review the Adverse
Benefit Determination. The notice of Our appeal decision will include the following:
a) The specific factual basis for Our decision in detailed and clear understandable language;
b) A reference to specific plan provisions on which the decision was based;
c) A statement that You, Your Health Care Provider, or Your Authorized Representative is entitled reasonable access to
and copies of all relevant documents, records, and criteria. This includes an explanation of clinical judgment on which
the decision was based and identification of the dental experts. All such information is available upon request and is
free of charge.
d) A statement of Your, Your Health Care Provider’s or Your Authorized Representative’s right to bring a civil action
under ERISA; and
e) a statement that the You, Your Health Care Provider, or Your Authorized Representative has a right to file an Appeal
with Us. Our internal appeal process must be exhausted before You may file a Complaint with the Commissioner of
Insurance.
f) a statement that You, Your Health Care Provider, or Your Authorized Representative may file a Complaint with the
Commissioner without first filing an Appeal, if the Coverage Decision involves an urgent medical condition for which care
has not been rendered. The Commissioner’s address is as follows:
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Phone: 410-468-2000 or 800-492-6116
Fax: 410-468-2270
g) a statement that the Health Advocacy Unit is available to assist You in both mediating and filing an Appeal under Our
internal appeal process. You may contact the Health Advocacy Unit at:
Health Education and Advocacy Unit
Consumer Protection Division
Office of the Attorney General
200 St. Paul Place, 16
th
Floor
Baltimore, MD 21202
Phone: 410-528-1840 or toll-free: 877-261-8807
Fax: 410-576-6571
Email: [email protected]e.md.us
Website: http://www.oag.state.md.us
Procedure for Post-Service Claim
You, Your Health Care Provider, or Your Authorized Representative may file an Appeal with Us upon the receipt of a
Coverage Decision. To file an Appeal, telephone the toll-free number listed on Your ID card.
We will review the claim and notify You of Our decision within thirty (30) working days of the request for an Appeal. Within
thirty (30) calendar days after a Coverage Decision has been made, We will send a written notice of the Coverage
Decision to You or Your Authorized Representative, and the treating provider.
MDDHMO Appeal-ADD (05/13)
The notice of Coverage Decision from Us shall include:
1. the specific factual basis for Our decision in detailed and clear, understandable language.
2. a statement that the You, Your Health Care Provider, or Your Authorized Representative has a right to file an
Appeal with Us. Our internal appeal process must be exhausted before You may file a Complaint with the
Commissioner of Insurance.
3. a statement that You, Your Health Care Provider, or Your Authorized Representative may file a Complaint with
the Commissioner without first filing an Appeal, if the Coverage Decision involves an urgent medical condition for
which care has not been rendered. The Commissioner’s address is as follows:
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Phone: 410-468-2000 or 800-492-6116
Fax: 410-468-2270
4. a statement that the Health Advocacy Unit is available to assist You in both mediating and filing an Appeal under
Our internal appeal process. You may contact the Health Advocacy Unit at:
Health Education and Advocacy Unit
Consumer Protection Division
Office of the Attorney General
200 St. Paul Place, 16
th
Floor
Baltimore, MD 21202
Phone: 410-528-1840 or toll-free: 877-261-8807
Fax: 410-576-6571
Email: [email protected]e.md.us
Website: http://www.oag.state.md.us
Appeals Procedure
You may request reconsideration of a Coverage Decision by submitting a written Appeal to Us. We will reconsider the
Coverage Decision. The Appeal will be reviewed and a final decision rendered. The final decision will be in writing to
You or Your Authorized Representative and the Health Care Provider, within sixty (60) working days after the date on
which the Appeal is filed.
The final decision will include a written notice of the Appeal decision. Written notice of the Appeal decision will be sent
within thirty (30) calendar days of the Appeal decision to You or Your Authorized Representative and the Health Care
Provider acting on Your behalf. The notice of the Appeal decision shall include the following:
a. the specific factual basis for Our decision in detailed and clear, understandable language.
b. that You, Your Health Care Provider, or Your Authorized Representative has a right to file a Complaint with the
Commissioner within four (4) months after receipt of Our Appeal decision, including the contact information as
indicated above.
c. a statement that You, Your Health Care Provider, or Your Authorized Representative may file a Complaint with
the Commissioner without first filing an Appeal, if the Coverage Decision involves an urgent medical condition for
which care has not been rendered. The Commissioner’s address is as follows:
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Phone: 410-468-2000 or 800-492-6116
Fax: 410-468-2270
d. a statement that the Health Advocacy Unit is available to assist You in both mediating and filing an Appeal under
Our internal appeal process. You may contact the Health Advocacy Unit at:
Health Education and Advocacy Unit
MDDHMO Appeal-ADD (05/13)
Consumer Protection Division
Office of the Attorney General
200 St. Paul Place, 16
th
Floor
Baltimore, MD 21202
Phone: 410-528-1840 or toll-free: 877-261-8807
Fax: 410-576-6571
Email: [email protected]e.md.us
Website: http://www.oag.state.md.us
Issues other than Coverage Decisions
For issues such as Complaints about Your dental office, enrollment issues, or the general operation of the Plan, please
contact the Maryland Insurance Administration at the address and telephone number listed above.
United Concordia Dental Plans, Inc.
Authorized Officer
FEDERAL LAW SUPPLEMENT
TO
CERTIFICATE OF INSURANCE
1 CHIPRA (11/09)
This Supplement amends your Certificate by adding the following provisions regarding special enrollment
periods and extended coverage requirements currently mandated or that may be mandated in the future
under federal law.
You may enroll for dental coverage at any time for yourself and your dependents if:
(1) You or your dependent either loses eligibility for coverage under Medicaid or the Children's
Health Insurance Program ("CHIP"); or
(2) You or your dependent becomes eligible for premium assistance from Medicaid or CHIP
allowing enrollment in a benefit program.
In order to enroll, you must submit complete enrollment information to your group or its plan administrator
within sixty (60) days from your or your dependent's loss of coverage or eligibility for premium
assistance, as the case may be.
Other special enrollment periods and rights may apply to you or your dependents under new or existing
federal laws. Consult your group, its plan administrator or your group's summary plan description for
information about any new or additional special enrollment periods, enrollment rights or extended
coverage periods for dependents mandated under federal law.
THE PROVIDER NETWORK AVAILABLE FOR MARYLAND
INCLUDES
DC, DE, PA, VA
Current Dental Terminology, © 2012 American Dental Association. All rights reserved. ST13ST13 (10/12) MD
CLINICAL ORAL EVALUATIONS
D0120 Periodic oral evaluation - established patient 0
D0140 Limited oral evaluation - problem focused 0
D0145 Oral evaluation for a patient under three years
of age and counseling with primary caregiver 0
D0150 Comprehensive oral evaluation - new or
established patient 0
D0170 Re-evaluation - limited, problem focused
(established patient; not post-operative visit) 0
D0180 Comprehensive periodontal evaluation - new
or established patient 0
RADIOGRAPHS/DIAGNOSTIC IMAGING
(including interpretation)
D0210 Intraoral - complete series of radiographic images 0
D0220 Intraoral-periapicalrstradiographicimage 0
D0230 Intraoral - periapical each additional radiographic
image 0
D0240 Intraoral - occlusal radiographic image 0
D0270 Bitewing - single radiographic image 0
D0272 Bitewings - two radiographic images 0
D0273 Bitewings - three radiographic images 0
D0274 Bitewings - four radiographic images 0
D0277 Vertical bitewings - 7 to 8 radiographic images 0
D0330 Panoramic radiographic image 0
D0340 Cephalometric radiographic image 0
TESTS AND EXAMINATIONS
D0460 Pulp vitality tests 0
D0470 Diagnostic casts 0
DENTAL PROPHYLAXIS
D1110 Prophylaxis - adult 0
D1120 Prophylaxis - child 0
TOPICAL FLUORIDE TREATMENT
0
(off ce procedure)
D1206 Topicalapplicationoffluoridevarnish
D1208 Topicalapplicationoffluoride
0
OTHER PREVENTIVE SERVICES
D1330 Oral hygiene instructions 0
D1351 Sealant - per tooth 0
SPACE MAINTENANCE
(passive appliances)
D1510 Spacemaintainer-xed-unilateral 0
D1515 Spacemaintainer-xed-bilateral 0
D1520 Space maintainer - removable - unilateral 0
D1555 Removalofxedspacemaintainer 0
AMALGAM RESTORATIONS
(including polishing)
D2140 Amalgam - one surface, primary or permanent 0
D2150 Amalgam - two surfaces, primary or permanent 0
D2160 Amalgam - three surfaces, primary or permanent 0
D2161 Amalgam - four or more surfaces, primary or
permanent 0
RESIN-BASED COMPOSITE RESTORATIONS - DIRECT
D2330 Resin-based composite - one surface, anterior 0
D2331 Resin-based composite - two surfaces, anterior 0
D2332 Resin-based composite - three surfaces, anterior 0
D2335 Resin-based composite - four or more surfaces or
involving incisal angle (anterior) 70
D2391 Resin-based composite - one surface, posterior 40
D2392 Resin-based composite - two surfaces, posterior 60
D2393 Resin-based composite - three surfaces, posterior 72
D2394 Resin-based composite - four or more surfaces,
posterior 84
INLAY/ONLAY RESTORATIONS
D2510 Inlay - metallic - one surface 60
D2520 Inlay - metallic - two surfaces 100
D2530 Inlay - metallic - three or more surfaces 120
D2542 Onlay - metallic - two surfaces 20
D2543 Onlay - metallic - three surfaces 30
D2544 Onlay - metallic - four or more surfaces 50
CROWNS - SINGLE RESTORATIONS ONLY
D2710 Crown - resin-based composite (indirect) 77
D2712 Crown - 3/4 resin-based composite (indirect) 86
D2740 Crown - porcelain/ceramic substrate 270
D2750 Crown - porcelain fused to high noble metal 276
D2751 Crown - porcelain fused to predominantly base
metal 258
D2752 Crown - porcelain fused to noble metal 270
D2780 Crown - 3/4 cast high noble metal 228
D2781 Crown - 3/4 cast predominantly base metal 228
D2782 Crown - 3/4 cast noble metal 228
D2783 Crown - 3/4 porcelain/ceramic 228
D2790 Crown - full cast high noble metal 228
IMPORTANT INFORMATION ABOUT YOUR PLAN
ADA ADA Member
CODE DESCRIPTION
Pays $
 ThisScheduleofBenetsprovidesalistingofprocedurescoveredbyYourPlan.ForproceduresthatrequireaCopayment,
theamounttobepaidisshowninthecolumntitled“MemberPays$.”YoupaytheseCopaymentstothedentalofceatthe
timeofservice.
 YoumustselectaUnitedConcordiaPrimaryDentalOfce(PDO)toreceiveCoveredServices.YourPDOwillperformthe
belowproceduresorreferYoutoaSpecialtyCareDentistforfurthercare.TreatmentbyanOutofNetworkDentistisnot
covered,exceptasdescribedintheCerticateofCoverage.
 OnlyprocedureslistedonthisScheduleofBenetsareCoveredServices.Forservicesnotlisted(notcovered),Youare
responsibleforthefullfeechargedbythedentist.ProcedurecodesandmemberCopaymentsmaybeupdatedtomeet
AmericanDentalAssociation(ADA)CurrentDentalTerminology(CDT)inaccordancewithnationalstandards.
 ForacompletedescriptionofYourPlan,pleaserefer totheCerticateofCoverageandtheScheduleof Exclusionsand
LimitationsinadditiontothisScheduleofBenets.
 IfYouhaveanyquestionsaboutYourUnitedConcordiaDentalPlan,pleasecallOurCustomerServiceDepartmenttollfree
at 1-888-638-3384 or access Our Website at www.unitedconcordia.com.
ADA ADA Member
CODE DESCRIPTION
Pays $
Concordia Plus Schedule of Benets
Plan ST13
Current Dental Terminology, © 2012 American Dental Association. All rights reserved. ST13ST13 (10/12) MD
D2791 Crown - full cast predominantly base metal 258
D2792 Crown - full cast noble metal 264
D2794 Crown - titanium 290
OTHER RESTORATIVE SERVICES
D2910 Recement inlay, onlay, or partial coverage
restoration 15
D2920 Recement crown 15
D2930 Prefabricated stainless steel crown - primary tooth 48
D2931 Prefabricated stainless steel crown - permanent
tooth 56
D2934 Prefabricated esthetic coated stainless steel
crown - primary tooth 48
D2940 Protective restoration 0
D2950 Core buildup, including any pins 100
D2951 Pin retention - per tooth, in addition to restoration 10
D2952 Post and core in addition to crown, indirectly
fabricated 108
D2953 Eachadditionalindirectlyfabricatedpost-same
tooth 45
D2954 Prefabricated post and core in addition to crown 108
D2957 Eachadditionalprefrabricatedpost-sametooth 45
D2970 Temporary crown (fractured tooth) 65
D2971 Additional procedures to construct new crown
underexistingpartialdentureframework 25
PULP CAPPING
D3110 Pulpcap-direct(excludingnalrestoration) 0
D3120 Pulpcap-indirect(excludingnalrestoration) 0
PULPOTOMY
D3220 Therapeuticpulpotomy(excludingnalrestoration)-
removal of pulp coronal to the dentinocemental
junction and application of medicament 25
D3221 Pulpal debridement, primary and permanent teeth 15
D3222 Partial pulpotomy for apexogenesis – permanent
tooth with incomplete root development 25
ENDODONTIC THERAPY ON PRIMARY TEETH
D3230 Pulpaltherapy(resorbablelling)-anterior,
primarytooth(excludingnalrestoration) 40
D3240 Pulpaltherapy(resorbablelling)-posterior,
primarytooth(excludingnalrestoration) 55
ENDODONTIC THERAPY
(including treatment plan, clinical procedures
and follow-up care)
D3310 Endodontictherapy,anteriortooth(excluding
nalrestoration) 108
D3320 Endodontictherapy,bicuspidtooth(excluding
nalrestoration) 144
D3330 Endodontictherapy,molar(excludingnal
restoration) 198
ENDODONTIC RETREATMENT
D3346 Retreatment of previous root canal therapy -
anterior 198
D3347 Retreatment of previous root canal therapy -
bicuspid 234
D3348 Retreatment of previous root canal therapy -
molar 288
APICOECTOMY/PERIRADICULAR SERVICES
D3410 Apicoectomy/periradicular surgery - anterior 107
D3421 Apicoectomy/periradicular surgery - bicuspid
(rstroot) 107
D3425 Apicoectomy/periradicular surgery - molar
(rstroot) 107
D3426 Apicoectomy/periradicular surgery (each
additional root) 41
D3450 Root amputation - per root 50
OTHER ENDODONTIC PROCEDURES
D3920 Hemisection (including any root removal),
not including root canal therapy 41
SURGICAL SERVICES
(including usual postoperative care)
D4210 Gingivectomy or gingivoplasty - four or more
contiguous teeth or tooth bounded spaces per
quadrant 125
D4211 Gingivectomy or gingivoplasty - one to three
contiguous teeth or tooth bounded spaces per
quadrant 50
D4212 Gingivectomy or gingivoplasty to allow access for
restorative procedure, per tooth 0
D4240 Gingivalapprocedure,includingrootplaning-
four or more contiguous teeth or tooth bounded
spacesperquadrant 135
D4241 Gingivalapprocedure,includingrootplaning-
one to three contiguous teeth or tooth bounded
spacesperquadrant 54
D4245 Apicallypositionedap 110
D4249 Clinical crown lengthening - hard tissue 105
D4260 Osseoussurgery(includingapentryand
closure) - four or more contiguous teeth or
toothboundedspacesperquadrant 210
D4261 Osseoussurgery(includingapentryand
closure) - one to three contiguous teeth or
toothboundedspacesperquadrant 110
D4263 Bonereplacementgraft-rstsiteinquadrant 115
D4274 Distal or proximal wedge procedure (when
not performed in conjunction with surgical
procedures in the same anatomical area) 45
D4275 Soft tissue allograft 100
D4276 Combined connective tissue and double pedicle
graft, per tooth 100
D4277 Freesofttissuegraftprocedure(includingdonor
sitesurgery),rsttoothoredentuloustooth
position in a graft 100
D4278 Freesofttissuegraftprocedure(includingdonor
site surgery), each additional contiguous tooth
or edentulous tooth position in same graft site 100
NON-SURGICAL PERIODONTAL SERVICES
D4320 Provisional splinting - intracoronal 40
D4321 Provisional splinting - extracoronal 40
D4341 Periodontal scaling and root planing - four or
moreteethperquadrant 60
D4342 Periodontal scaling and root planing - one to
threeteethperquadrant 16
D4355 Fullmouthdebridementtoenablecomprehensive
evaluation and diagnosis 50
D4381 Localized delivery of antimicrobial agents via
controlled release vehicle into diseased crevicular
tissue, per tooth 100
OTHER PERIODONTAL SERVICES
D4910 Periodontal maintenance 30
ADA ADA Member
CODE DESCRIPTION Pays $
ADA ADA Member
CODE DESCRIPTION Pays $
Current Dental Terminology, © 2012 American Dental Association. All rights reserved. ST13ST13 (10/12) MD
COMPLETE DENTURES
(including routine post-delivery care)
D5110 Complete denture - maxillary 264
D5120 Complete denture - mandibular 264
D5130 Immediate denture - maxillary 288
D5140 Immediate denture - mandibular 288
PARTIAL DENTURES
(including routine post-delivery care)
D5211 Maxillary partial denture - resin base (including
any conventional clasps, rests and teeth) 174
D5212 Mandibular partial denture - resin base (including
any conventional clasps, rests and teeth) 174
D5213 Maxillarypartialdenture-castmetalframework
with resin denture bases (including any
conventional clasps, rests and teeth) 270
D5214 Mandibularpartialdenture-castmetalframework
with resin denture bases (including any
conventional clasps, rests and teeth) 270
D5225 Maxillarypartialdenture-exiblebase(including
any clasps, rests and teeth) 350
D5226 Mandibular
partialdenture-exiblebase
(including any clasps, rests and teeth) 350
D5281 Removable unilateral partial denture - one piece
cast metal (including clasps and teeth) 78
ADJUSTMENTS TO DENTURES
D5410 Adjust complete denture - maxillary 7
D5411 Adjust complete denture - mandibular 7
D5421 Adjust partial denture - maxillary 7
D5422 Adjust partial denture - mandibular 7
REPAIRS TO COMPLETE DENTURES
D5510 Repairbrokencompletedenturebase 21
D5520 Replacemissingorbrokenteeth-complete
denture (each tooth) 28
REPAIRS TO PARTIAL DENTURES
D5610 Repair resin denture base 23
D5620 Repaircastframework 33
D5630 Repairorreplacebrokenclasp 23
D5640 Replacebrokenteeth-pertooth 18
D5650 Add tooth to existing partial denture 23
D5660 Add clasp to existing partial denture 33
D5670 Replace all teeth and acrylic on cast metal
framework(maxillary) 147
D5671 Replace all teeth and acrylic on cast metal
framework(mandibular) 147
DENTURE REBASE PROCEDURES
D5710 Rebase complete maxillary denture 55
D5711 Rebase complete mandibular denture 55
D5720 Rebase maxillary partial denture 48
D5721 Rebase mandibular partial denture 48
DENTURE RELINE PROCEDURES
D5730 Reline complete maxillary denture (chairside) 40
D5731 Reline complete mandibular denture (chairside) 40
D5740 Reline maxillary partial denture (chairside) 40
D5741 Reline mandibular partial denture (chairside) 40
D5750 Reline complete maxillary denture (laboratory) 55
D5751 Reline complete mandibular denture (laboratory) 55
D5760 Reline maxillary partial denture (laboratory) 55
D5761 Reline mandibular partial denture (laboratory) 55
INTERIM PROSTHESIS
D5810 Interim complete denture (maxillary) 125
D5811 Interim complete denture (mandibular) 125
D5820 Interim partial denture (maxillary) 105
D5821 Interim partial denture (mandibular) 105
OTHER REMOVABLE PROSTHETIC SERVICES
D5850 Tissue conditioning, maxillary 25
D5851 Tissue conditioning, mandibular 25
SURGICAL SERVICES
D6010 Surgical placement of implant body: endosteal
implant 1983
D6040 Surgical placement: eposteal implant 1983
D6050 Surgical placement: transosteal implant 1783
D6100 Implant removal, by report 172
IMPLANT SUPPORTED PROSTHETICS
D6058 Abutment supported porcelain/ceramic crown 1030
D6059 Abutment supported porcelain fused to metal
crown (high noble metal) 1030
D6060 Abutment supported porcelain fused to metal
crown (predominantly base metal) 970
D6061 Abutment supported porcelain fused to metal
crown (noble metal) 985
D6062 Abutment supported cast metal crown (high
noble metal) 1036
D6063 Abutment supported cast metal crown
(predominantly base metal) 925
D6064 Abutment supported cast metal crown (noble
metal) 985
D6065 Implant supported porcelain/ceramic crown 1030
D6066 Implant supported porcelain fused to metal crown
(titanium, titanium alloy, high noble metal) 1030
D6067 Implant supported metal crown (titanium, titanium
alloy, high noble metal) 1036
D6094 Abutment supported crown – (titanium) 987
OTHER IMPLANT SERVICES
D6092 Recement implant/abutment supported crown 66
D6095 Repair implant abutment, by report 166
FIXED PARTIAL DENTURE PONTICS
D6205 Pontic - indirect resin based composite 290
D6210 Pontic - cast high noble metal 276
D6211 Pontic - cast predominantly base metal 258
D6212 Pontic - cast noble metal 264
D6214 Pontic - titanium 297
D6240 Pontic - porcelain fused to high noble metal 276
D6241 Pontic - porcelain fused to predominantly
base metal 258
D6242 Pontic - porcelain fused to noble metal 264
D6245 Pontic - porcelain/ceramic 258
FIXED PARTIAL DENTURE RETAINERS - INLAYS/ONLAYS
D6610 Onlay - cast high noble metal, two surfaces 150
D6612 Onlay - cast predominantly base metal,
two surfaces 100
D6614 Onlay - cast noble metal, two surfaces 125
FIXED PARTIAL DENTURE RETAINERS - CROWNS
D6710 Crown - indirect resin based composite 290
D6740 Crown - porcelain/ceramic 258
D6750 Crown - porcelain fused to high noble metal 276
D6751 Crown - porcelain fused to predominantly
base metal 258
D6752 Crown - porcelain fused to noble metal 264
D6790 Crown - full cast high noble metal 276
D6791 Crown - full cast predominantly base metal 258
ADA ADA Member
CODE DESCRIPTION Pays $
ADA ADA Member
CODE DESCRIPTION Pays $
Current Dental Terminology, © 2012 American Dental Association. All rights reserved. ST13ST13 (10/12) MD
D6792 Crown - full cast noble metal 264
D6794 Crown - titanium 290
OTHER FIXED PARTIAL DENTURE SERVICES
D6930 Recementxedpartialdenture 17
EXTRACTIONS
(includes local anesthesia, suturing, if needed, and
routine postoperative care)
D7111 Extraction,coronalremnants-deciduoustooth 8
D7140 Extraction,eruptedtoothorexposedroot
(elevation and/or forceps removal) 20
SURGICAL EXTRACTIONS
(includes local anesthesia, suturing, if needed, and
routine postoperative care)
D7210 Surgicalremovaloferuptedtoothrequiringremoval
of bone and/or sectioning of tooth, and including
elevationofmucoperiostealapifindicated 27
D7220 Removal of impacted tooth - soft tissue 45
D7230 Removal of impacted tooth - partially bony 55
D7240 Removal of impacted tooth - completely bony 65
D7241 Removal of impacted tooth - completely bony,
with unusual surgical complications 80
D7250 Surgical removal of residual tooth roots
(cutting procedure) 35
D7251 Coronectomy - intentional partial tooth removal 65
OTHER SURGICAL PROCEDURES
D7280 Surgical access of an unerupted tooth 52
D7283 Placement of device to facilitate eruption of
impacted tooth 13
D7285 Biopsy of oral tissue - hard (bone, tooth) 35
D7286 Biopsy of oral tissue - soft 28
D7288 Brush biopsy - transepithelial sample
collection 45
ALVEOLOPLASTY
(surgical preparation of ridge for dentures)
D7310 Alveoloplasty in conjunction with extractions -
fourormoreteethortoothspaces,perquadrant 23
D7320 Alveoloplasty not in conjunction with extractions -
fourormoreteethortoothspaces,perquadrant 30
D7321 Alveoloplasty not in conjunction with extractions -
onetothreeteethortoothspaces,perquadrant 30
SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS
D7450 Removal of benign odontogenic cyst or tumor -
lesiondiameterupto1.25cm 60
EXCISION OF BONE TISSUE
D7471 Removal of lateral exostosis (maxilla or mandible) 60
D7472 Removal of torus palatinus 60
D7473 Removal of torus mandibularis 60
D7485 Surgical reduction of osseous tuberosity 60
SURGICAL INCISION
D7510 Incision and drainage of abscess - intraoral
soft tissue 35
OTHER REPAIR PROCEDURES
D7960 Frenulectomy–alsoknownasfrenectomyor
frenotomy - separate procedure not incidental to
another procedure 53
D7963 Frenuloplasty 27
D7972 Surgicalreductionofbroustuberosity 60
LIMITED ORTHODONTIC TREATMENT
D8010 Limited orthodontic treatment of the primary
dentition 380
D8020 Limited orthodontic treatment of the transitional
dentition 405
D8030 Limited orthodontic treatment of the adolescent
dentition 430
D8040 Limited orthodontic treatment of the adult
dentition 455
INTERCEPTIVE ORTHODONTIC TREATMENT
D8050 Interceptive orthodontic treatment of the
primary dentition 650
D8060 Interceptive orthodontic treatment of the
transitional dentition 750
COMPREHENSIVE ORTHODONTIC TREATMENT ×
D8070 Comprehensive orthodontic treatment of the
transitional dentition 1,800
D8080 Comprehensive orthodontic treatment of the
adolescent dentition 1,950
D8090 Comprehensive orthodontic treatment of the
adult dentition 2,200
MINOR TREATMENT TO CONTROL HARMFUL HABITS
D8210 Removable appliance therapy 390
D8220 Fixedappliancetherapy 370
OTHER ORTHODONTIC SERVICES
D8680 Orthodontic retention (removal of appliances,
construction and placement of retainer(s)) 150
Orthodontic records fee 150
UNCLASSIFIED TREATMENT
D9110 Palliative (emergency) treatment of dental pain -
minor procedure 15
ANESTHESIA
D9210 Local anesthesia not in conjunction with operative
or surgical procedures 20
D9211 Regionalblockanesthesia 26
D9212 Trigeminaldivisionblockanesthesia 15
D9215 Local anesthesia in conjunction with operative or
surgical procedures 18
D9220 Deepsedation/generalanesthesia-rst
30 minutes 205
D9221 Deep sedation/general anesthesia - each
additional 15 minutes 103
D9241 Intravenous conscious sedation/analgesia -
rst30minutes 205
D9242 Intravenous conscious sedation/analgesia -
each additional 15 minutes 100
PROFESSIONAL CONSULTATION
D9310 Consultation - diagnostic service provided by
dentistorphysicianotherthanrequestingdentist
or physician 20
PROFESSIONAL VISITS
D9430 Ofcevisitforobservation(duringregularly
scheduled hours) - no other services performed 0
D9440 Ofcevisit,afterregularlyscheduledhours 30
DRUGS
D9630 Other drugs and/or medicaments, by report 20
MISCELLANEOUS SERVICES
D9951 Occlusal adjustment - limited 20
D9952 Occlusal adjustment - complete 45
FOOTNOTES
Twofluoridetreatmentsperc
alendaryearthrough age
18.
ADA ADA Member
CODE DESCRIPTION Pays $
ADA ADA Member
CODE DESCRIPTION Pays $
Current Dental Terminology, © 2012 American Dental Association. All rights reserved. ST13ST13 (10/12) MD
ADA ADA Member ADA ADA Member
CODE DESCRIPTION Pays $
CODE DESCRIPTION Pays $
FOOTNOTES
× Limitedtoastandard24monthtreatment.
PleasereportundercodeD8999“Unspeciedorthodontic
procedure,byreport.”Recordsincludealldiagnostic
procedures,suchascephalometriclms,fullmouth
x-rays,models,andtreatmentplans.
MD9810 (10/12)
SCHEDULE OF EXCLUSIONS AND LIMITATIONS
EXCLUSIONS
Except as specifically provided in this Certificate, Schedules of Benefits, Riders to the Certificate, no coverage will be
provided for services, supplies or charges:
1. Not specifically listed in the Schedule of Benefits as a
Covered Service.
2. Provided to Members by Out-of-Network Dentists
except when immediate dental treatment is required as
a result of a Dental Emergency occurring more than 50
miles from the Member’s home.
3. That are necessary due to lack of cooperation with
Primary Dental Office, or failure to comply with a
professionally prescribed Treatment Plan.
4. Started or incurred prior to the Member’s Effective Date
of Coverage with the Company or started after the
Termination Date of Coverage with the Company.
5. For consultations by a Specialty Care Dentist for
services not specifically listed on the Schedule of
Benefits as a Covered Service.
6. Services or supplies that are not deemed generally
accepted standards of dental treatment.
7. That are the responsibility of Workers’ Compensation
or employer’s liability insurance. The Company’s
benefits would be in excess to the third party benefits
and therefore, the Company would have right of
recovery for any benefits paid in excess.
8. Services and/or appliances that alter the vertical
dimension, including, but not limited to, full mouth
rehabilitation, splinting, fillings to restore tooth structure
lost from attrition, erosion or abrasion, appliances or
any other method.
9. That restore tooth structure due to attrition, erosion or
abrasion.
10. For periodontal splinting of teeth by any method.
11. For replacement of lost, missing, stolen or damaged
prosthetic device or orthodontic appliance or for
duplicate dentures, prosthetic devices or any
duplicative device.
12. For replacement of existing dentures that are, or can be
made serviceable.
13. For prosthetic reconstruction or other services which
require a prosthodontist.
14. For assistant at surgery.
15. For elective procedures, including prophylactic
extraction of third molars.
16. For congenital mouth malformations or skeletal
imbalances, including, but not limited to, treatment
related to cleft palate, disharmony of facial bone, or
required as the result of orthognathic surgery, including
orthodontic treatment, and oral and maxillofacial
services, associated hospital and facility fees,
anesthesia, and radiographic imaging even if the
condition requiring these services involves part of the
body other than the mouth or teeth. This exclusion shall
not apply to newly born children of Members as defined
in the definition of Dependent.
17. For diagnostic services and treatment of jaw joint
problems by any method. These jaw joint problems
include but are not limited to such conditions as
temporomandibular joint disorder (TMD) and
craniomandibular disorders or other conditions of the
joint linking the jaw bone and the complex of muscles,
nerves and other tissues related to that joint.
18. For implants, surgical insertion and/or removal of, and
any appliances and/or crowns attached to implants.
19. For the following, which are not included as orthodontic
benefits: retreatment of orthodontic cases, changes in
orthodontic treatment necessitated by patient non-
cooperation, repair of orthodontic appliances,
replacement of lost or stolen appliances, special
appliances (including, but not limited to, headgear,
orthopedic appliances, bite planes, functional
appliances or palatal expanders), myofunctional
therapy, cases involving orthognathic surgery,
extractions for orthodontic purposes, and treatment in
excess of 24 months.
20. For active orthodontic treatment if started prior to a
Member’s effective date.
21. For prescription or nonprescription drugs, home care
items, vitamins or dietary supplements.
22. For hospitalization and associated costs for rendering
services in a hospital.
23. For house or hospital calls for dental services.
24. For any dental or medical services performed by a
physician and/or services which benefits are otherwise
provided under a health care plan of the employer.
25. Which are Cosmetic in nature as determined by the
Company, including, bleaching, veneer facings,
personalization or characterization of crowns, bridges
and/or dentures.
MD9810 (10/12)
26. For broken appointments.
27. For any condition caused by or resulting from declared
or undeclared war or act thereof, or resulting from
service in the national guard or in the armed forces of
any country or international authority.
LIMITATIONS
The following services, if listed on the Schedule of Benefits, will be subject to limitations as set forth below. A ”benefit
accumulation year,” as used in this Schedule, means the time period under the Group Contract during which the Plan’s Covered
Services accrue and is either a calendar year (12 months beginning in January and ending in December) or a contract year
(12 months beginning with the Effective Date of the Group Contract).
1. Bitewing x-rays – one set(s) per six consecutive
months through age 13, and one set(s) of bitewing x-
rays per 12 consecutive months for age 14 and older.
2. Panoramic or full mouth x-rays – one per three-year
period.
3. Prophylaxis – two per benefit accumulation year.
4. Routine prophylaxis and periodontal maintenance
procedures are limited to no more than two per benefit
accumulation year
5. Sealants – one per tooth per three year(s) through age
15 on permanent first and second molars.
6. Fluoride treatment – two per benefit accumulation year
through age 18.
7. Space maintainers only eligible for Members through
age 18 when used to maintain space as a result of
prematurely lost deciduous first and second molars, or
permanent first molars that have not, or will never
develop.
8. Restorations, crowns, inlays and onlays – covered only
if necessary to treat diseased or fractured teeth.
9. Crowns, bridges, inlays, onlays, buildups, post and
cores – one per tooth in a five-year period.
10. Crown lengthening – one per tooth per lifetime.
11. Referral for specialty care is limited to orthodontics, oral
surgery, periodontics, endodontics, and pediatric
dentists.
This limitation does not apply if the service was
provided as a result of a standing or non-network
referral as described in the Certificate of Coverage.
12. Coverage for referral to a pediatric Specialty Care
Dentist ends on a Member’s seventh birthday.
13. Pupal therapy – through age five on primary anterior
teeth and through age 11 on primary posterior teeth.
14. Root canal treatment – one per tooth per lifetime.
15. Root canal retreatment – one per tooth per lifetime.
16. Periodontal scaling and root planing – one per 24
consecutive month period per area of the mouth.
17. Surgical periodontal procedures – one per 24
consecutive month period per area of the mouth.
18. Full and partial dentures – one per arch in a five-year
period.
19. Denture relining, rebasing or adjustments – are
included in the denture charges if provided within six
months of insertion by the same dentist.
20. Subsequent denture relining or rebasing – limited to
one every 36 consecutive months thereafter.
21. Oral surgery services are limited to surgical exposure
of teeth, removal of teeth, preparation of the mouth for
dentures, removal of tooth generated cysts up to
1.25cm, frenectomy and crown lengthening.
22. Wisdom teeth (third molars) extracted for Members
under age 15 or over age 30 are not eligible for
payment in the absence of specific pathology.
23. If for any reason orthodontic services are terminated or
coverage under the Company is terminated before
completion of the approved orthodontic treatment, the
responsibility of the Company will cease 60 days after
termination if paid monthly or the later of 60 days after
termination or the end of the quarter in progress if paid
quarterly. This extension of orthodontic payment does
not apply if coverage was terminated due to failure of
the individual to pay required Premium, fraud, or
material misrepresentation by the individual, or if
succeeding coverage is provided by another health
plan and the cost to the individual is less than or equal
to the cost to the individual of coverage during the
extension and there is no interruption of benefits.
24. Orthodontic treatment – not eligible for Members over
age 18 unless listed otherwise in the Member's
Schedule of Benefits.
25. Comprehensive orthodontic treatment plan – one per
lifetime.
MD9810 (10/12)
26. In the case of a Dental Emergency involving pain or a
condition requiring immediate treatment, the Plan
covers necessary diagnostic and therapeutic dental
procedures administered by an Out-of-Network Dentist
up to the difference between the Out-of-Network
Dentist's charge and the Member Copayment up to a
maximum of $50 for each emergency visit.
27. Administration of I.V. sedation or general anesthesia is
limited to covered oral surgical procedures involving one
or more impacted teeth (soft tissue, partial bony or complete
bony impactions).
28. An Alternative Benefit Provision (ABP) may be applied by
the Primary Dental Office if a dental condition can be treated
by means of a professionally acceptable procedure, which is
less costly than the treatment recommended by the dentist.
The ABP does not commit the Member to the less costly
treatment. However, if the Member and the dentist choose
the more expensive treatment, the Member is responsible
for the additional charges beyond those allowed for the
ABP.
MDR-HF-PR (10/12)
United Concordia
Rider to Schedule of Benefits and
Schedule of Exclusions and Limitations
Maternity Dental Benefit
This Rider is effective on January 1, 2014 and is attached to and made a part of the Schedules of
Benefits and Schedule of Exclusions and Limitations.
SCHEDULE OF EXCLUSIONS AND LIMITATIONS:
The following limitation is substituted for the limitation on prophylaxis in the Schedule of
Exclusions and Limitations:
Prophylaxis – two per benefit accumulation year, unless otherwise specified in the Schedule of
Benefits. One additional Prophylaxis in a twelve consecutive month period for Members under the
care of a medical professional for pregnancy.
SCHEDULE OF BENEFITS:
Member Copayments on the Schedule of Benefits shall apply to the additional prophylaxis
provided to a Member under the care of a medical professional for pregnancy.
UNITED CONCORDIA DENTAL PLANS, INC.
Authorized Officer
