United Concordia Dental Benefits
for State of Maryland Employees and Retirees
Dental Preferred Provider Organization (DPPO)
January 1, 2021 to December 31, 2021
If you are not already enrolled in the DPPO plan
you can enroll during open enrollment
October 19, 2020 through November 13, 2020.
DPPO Members
If you are currently enrolled in the United Concordia Dental PPO
plan, if you choose to remain in the DPPO plan, you do not need
to do anything during open enrollment.
Questions on the State of Maryland DPPO plan?
Call United Concordia at 1-888-638-3384
(TTY Hearing Impaired 1-800-345-3837)
Visit www.UnitedConcordia.com
How to Enroll in a Dental Plan
from United Concordia
UnitedConcordia.com • 1-888-638-3384
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United Concordia Dental PPO Plan High Level Summary
Plan Characteristics DPPO
In-network benefits and out-of-network benefits available Yes
National access Yes
Must use an assigned dentist No
Claim required with out-of-network care Yes
1
Balance billing for covered services out-of-network Yes
1
Referral required for specialty care No
Orthodontia benefits available
Yes
(for dependent children only)
Orthodontia maximum (lifetime) $2,000
Benefit maximum (per person) $2,500
2
Deductible (per person) $50
3
Deductible (per family) $150
3
1. Applies when visiting any nonparticipating dentist under this plan.
2. Excludes covered Class I Services.
3. Deductible does not apply to Class I–Diagnostic and Preventive Services, and Class IV–Orthodontic Services.
Biological children, stepchildren and adopted children are covered through end of the month in which they turn 26.
Other child dependents—grandchildren, step grandchildren, legal wards, and other child relatives—are only covered
until the end of the month in which they turn 25.
Benefit maximum and deductibles are for the period of January 1, 2021–December 31, 2021.
All services are subject to the contract, Schedules of Benefits, and the Exclusions and Limitations.
UnitedConcordia.com • 1-888-638-3384
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How the United Concordia DPPO Plan Works
• Members may utilize participating and/or nonparticipating dentists.
• Preventive and diagnostic procedures (cleanings, exams, x-rays, etc.) do not count toward your
$2,500 program maximum.
• There is a deductible of $50 per person/$150 per family, excluding Class I–Diagnostic and Preventive
Services and Class IV–Orthodontic Services.
• The Smile for Health® Maternity Dental Benefit provides women with an additional dental cleaning
during pregnancy. This extra cleaning can help control pregnancy gingivitis and help prevent
periodontal (gum) disease, which has been linked to premature and low-birthweight babies.
• There is a maximum benefit of $2,500 per member per contract year (January 1, 2021
–
December 31,
2021) for services received under the DPPO plan. Your plan includes the Preventive Incentive®
feature,
in which covered Class I services do not count toward the maximum benefit.
• When care is received from an Advantage Plus network dentist, there are no claim forms to submit
and you are only responsible for coinsurance amounts and applicable deductibles. If you receive
services from a nonparticipating dentist, claim forms must be submitted and you are subject to
balance billing.
• You do not need a referral to receive care from a specialist.
• Orthodontic benefits are available for biological children, stepchildren and adopted children are
covered through end of the month in which they turn 26. Other child dependents—grandchildren,
step grandchildren, legal wards, and other child relatives—are only covered until the end of the
month in which they turn 25. The orthodontia lifetime maximum is $2,000. Orthodontic services are
available from participating and nonparticipating dentists.
• The DPPO plan is available anywhere in the U.S.
DPPO Network of Dentists
To receive in-network benefits, members must receive services from a dentist who participates in the
Advantage Plus network. You always have the option of receiving care from non-network dentists under the
DPPO plan. You can search for an Advantage Plus network dentist by visiting www.UnitedConcordia.com/
statemd and selecting DPPO on the left side of the page. You can Search for an Advantage Plus Network
Dentist by clicking the Advantage Plus button in the middle of the screen.
Financial Responsibility of Plan Member
Deductibles and coinsurance are the responsibility of the plan member. Before you receive any services, be
sure to review your dental plan design to ensure that you have anticipated all out-of-pocket costs and
liabilities associated with a particular treatment. If your dental treatment is estimated to cost $500 or more,
you may want to ask your dentist to request a predetermination of benefits. You are encouraged to discuss
major procedures and your financial liability with your dentist. You may also contact United Concordia’s
Customer Service Department to determine your financial responsibility. If calling Customer Service, please
have the ADA procedure code, dentist’s name and dentist’s charge available (you can get this information
from your dentist).
Dental Preferred Provider Organization (PPO) Plan
UnitedConcordia.com • 1-888-638-3384
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Are there any benefit maximums?
Yes, there is a benefit maximum of $2,500 per member (for the plan year, January 1, 2021
–December 31,
2021). There is a lifetime orthodontia maximum of $2,000 for dependent children. Biological children,
stepchildren and adopted children are covered through end of the month in which they turn 26.
All other child dependents—grandchildren, step grandchildren, legal wards, and other child relatives—
are only covered until the end of the month in which they turn 25.
Do I have to fill out claim forms after each routine visit?
If you receive care from a Concordia Advantage Plus network dentist, you do not need to fill out claim
forms—your dentist will take care of the paperwork. Under the DPPO plan, you must submit claim forms
if you are seeking reimbursement for services performed by an out-of-network dentist.
If my dentist does not participate in the Advantage Plus network, can I still see him or her?
Yes, you can receive care from any licensed dentist. If you choose to see a nonparticipating dentist,
you will be responsible for the deductible and/or coinsurance amount, as well as any charges over and
above United Concordia’s reimbursement for covered services. Advantage Plus network dentists accept
United Concordia’s reimbursement as payment in full for covered services, which means you are only
responsible for the applicable deductible and/or coinsurance amount.
Can I obtain the charge and coinsurance amount for specific services prior to receiving treatment?
Yes, simply obtain the ADA procedure code and dentist’s charge from your dentist’s office. Contact
United Concordia’s Customer Service Department at 1-888-638-3384 with this information and they
can provide you with your financial responsibility for the service, including any deductibles and
coinsurance amounts.
How can I obtain a directory of participating dentists?
Either call 1-888-638-3384 or visit www.UnitedConcordia.com/statemd and select DPPO on the left
side of the page. You can Search for an Advantage Plus Dentist at UnitedConcordia.com/statemd.
To receive in-network benefits, members must receive services from dentists in the Advantage Plus
network. You always have the option of receiving care from non-network dentists under the DPPO plan.
Do I have to be referred to a specialist?
No. Under the DPPO plan, referrals are not required. To maximize your benefits, you may wish to utilize a
participating dentist.
Who is eligible to receive fluoride treatments?
Eligible dependent children through age 18.
What about orthodontia for children?
Orthodontic benefits are available for biological children, stepchildren and adopted children through
end of the month in which they turn 26. All other child dependents—grandchildren, step grandchildren,
legal wards, and other child relatives—are only covered until the end of the month in which they turn
25. Orthodontic benefits can be received from participating and nonparticipating dentists. There is a
lifetime orthodontic maximum of $2,000 per covered dependent child. There is no adult orthodontic
coverage under the United Concordia DPPO plan.
Q&A for United Concordia DPPO Members
UnitedConcordia.com • 1-888-638-3384
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1. Plan payments, member coinsurances and deductibles are based on the maximum allowable charge.
In-Network dentists accept the maximum allowable charge as payment in full.
2. Members utilizing out-of-network dentists may be subject to balance billing by their dentist.
3. Eligible dependents through age 18.
4. An alternate benet provision may be applied (see LIMITATIONS
–
DPPO).
5. Biological children, stepchildren and adopted children are covered through end of the month in which they turn 26. Other child dependents—
grandchildren, step grandchildren, legal wards, and other child relatives—are only covered until the end of the month in which they turn 25.
Concordia DPPO Benefit Summary
BENEFIT CATEGORY
In-Network
Plan Pays
1
Out-of-Network
Plan Pays
2
Class I—Diagnostic and Preventive (Excluded from Annual Program Maximum)
Exams
100% 100%
All Eligible X-Rays
Cleanings (includes 1 additional cleaning during pregnancy)
Fluoride Treatments
3
Sealants
Palliative Treatment
Class II—Basic Services
Basic Restorative
70% 70%
Space Maintainers
Endodontics
Nonsurgical Periodontics
Repairs of Crowns, Inlays, Onlays, Bridges and Dentures
Simple Extractions
Surgical Periodontics
Complex Oral Surgery
General Anesthesia and/or IV Sedation
Class III—Major Restorative
Inlays, Onlays, Crowns
4
50% 50%
Implants
Prosthetics
Orthodontics (dependent children only)
Diagnostic, Active, Retention Treatment
50% 50%
Deductibles and Maximums
$50/$150 Deductible (excludes Class I–Diagnostic and Preventive services, and Class IV–Orthodontic Services)
$2,500 Contract Maximum per Member during the period of January 1st–December 31st
(excludes covered Class I services)
$2,000 Lifetime Orthodontia Maximum for dependent children. Orthodontic coverage for dependent children
will cease at the end of the month in which the child turns 26.
5
• Members may utilize participating and/or nonparticipating dentists
• Members cannot be balance billed when utilizing in-network dentists
• Deductibles and maximums apply
• Claim submission is required for services provided by nonparticipating (out-of-network) dentists
• Orthodontia benefits are available for dependent children only
• This is only a benefits summary; to verify benefits and eligibility, please contact Customer Service at 1-888-638-3384
UnitedConcordia.com • 1-888-638-3384
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Exclusions and Limitations – DPPO
STMD (01/14)
SCHEDULE OF EXCLUSIONS AND LIMITATIONS
EXCLUSIONS – DPPO Plan
Except as specifically provided in the Certificate, Schedules of Benefits or Riders to the Certificate, no coverage will
be provided for services, supplies or charges:
1. Not specifically listed as a Covered Service on the
Schedule of Benefits and those listed as not
covered on the Schedule of Benefits.
2. Which are necessary due to patient neglect, lack
of cooperation with the treating dentist or failure to
comply with a professionally prescribed Treatment
Plan.
3. Started prior to the Member’s Effective Date or
after the Termination Date of coverage with the
Company, including, but not limited to multi-visit
procedures such as endodontics, crowns, bridges,
inlays, onlays, and dentures.
4. Services or supplies that are not deemed
generally accepted standards of dental treatment.
5. For hospitalization costs.
6. For prescription or non-prescription drugs,
vitamins, or dietary supplements.
7. Administration of nitrous oxide, general
anesthesia and i.v. sedation, unless specifically
indicated on the Schedule of Benefits.
8. Which are Cosmetic in nature as determined by
the Company, including, but not limited to
bleaching, veneer facings, personalization or
characterization of crowns, bridges and/or
dentures.
9. Elective procedures including but not limited to the
prophylactic extraction of third molars.
10. For the following which are not included as
orthodontic benefits - retreatment of orthodontic
cases, changes in orthodontic treatment
necessitated by patient neglect, or repair of an
orthodontic appliance.
11. For congenital mouth malformations or skeletal
imbalances, including, but not limited to treatment
related to cleft lip or cleft palate, disharmony of
facial bone, or required as the result of
orthognathic surgery including orthodontic
treatment.
12. For dental implants including placement and
restoration of implants unless specifically covered
under a rider to the Certificate.
13. For oral or maxillofacial services including but not
limited to associated hospital, facility, anesthesia,
and radiographic imaging even if the condition
requiring these services involves part of the body
other than the mouth or teeth.
14. Diagnostic services and treatment of jaw joint
problems by any method unless specifically
covered under a Rider to the Certificate. 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 the joint.
15. For treatment of fractures and dislocations of the
jaw.
16. For treatment of malignancies or neoplasms.
17. 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.
18. Replacement of lost, stolen or damaged prosthetic
or orthodontic appliances.
19. For broken appointments.
20. For house or hospital calls for dental services.
21. Replacement of existing crowns, onlays, bridges and
dentures that are or can be made serviceable.
22. Preventive restorations in the absence of dental
disease.
23. Periodontal splinting of teeth by any method.
24. For duplicate dentures, prosthetic devices or any
other duplicative device.
25. For services determined to be furnished as a
result of a prohibited referral. “Prohibited referral”
means a referral prohibited by Section 1-302 of
the Health Occupations Article. Prohibited
referrals are referrals of a patient to an entity in
which the referring dentist, or the dentist’s
immediate family: (a) owns a beneficial interest; or
(b) has a compensation arrangement. The
dentist’s immediate family includes the spouse,
child, child’s spouse, parent, spouse’s parent,
sibling, or sibling’s spouse of the dentist, or that
dentist in combination.
26. For which in the absence of insurance the
Member would incur no charge.
27. For plaque control programs, oral hygiene, and
dietary instructions.
28. 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.
EXCLUSIONS AND LIMITATIONS
EXCLUSIONS – DPPO Plan
Except as specifically provided in the Certificate, Schedules of Benefits or Riders to the Certificate, no coverage will be
provided for services, supplies or charges:
1. Not specifically listed as a Covered Service on
the Schedule of Benefits and those listed as not
covered on the Schedule of Benefits.
2. Which are necessary due to patient neglect, lack
of cooperation with the treating dentist or failure
to comply with a professionally prescribed
Treatment Plan.
3. Started prior to the Member’s Effective Date or
after the Termination Date of coverage with the
Company, including, but not limited to multi-visit
procedures such as endodontics, crowns,
bridges, inlays, onlays, and dentures.
4. Services or supplies that are not deemed
generally accepted standards of dental
treatment.
5. For hospitalization costs.
6. For prescription or non-prescription drugs,
vitamins, or dietary supplements.
7. Administration of nitrous oxide, general
anesthesia and i.v. sedation, unless specifically
indicated on the Schedule of Benefits.
8. Which are Cosmetic in nature as determined by
the Company, including, but not limited to
bleaching, veneer facings, personalization or
characterization of crowns, bridges and/or
dentures.
9. Elective procedures including but not limited to
the prophylactic extraction of third molars.
10. For the following which are not included as
orthodontic benefits - retreatment of orthodontic
cases, changes in orthodontic treatment
necessitated by patient neglect, or repair of an
orthodontic appliance.
11. For congenital mouth malformations or skeletal
imbalances, including, but not limited to
treatment related to cleft lip or cleft palate,
disharmony of facial bone, or required as the
result of orthognathic surgery including
orthodontic treatment.
12. For dental implants including placement and
restoration of implants unless specifically
covered under a rider to the Certificate.
13. For oral or maxillofacial services including but
not limited to associated hospital, facility,
anesthesia, and radiographic imaging even if the
condition requiring these services involves part
of the body other than the mouth or teeth.
14. Diagnostic services and treatment of jaw joint
problems by any method unless specifically
covered under a Rider to the Certificate. 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 the joint.
15. For treatment of fractures and dislocations of the
jaw.
16. For treatment of malignancies or neoplasms.
17. 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.
18. Replacement of lost, stolen or damaged
prosthetic or orthodontic appliances.
19. For broken appointments.
20. For house or hospital calls for dental services.
21. Replacement of existing crowns, onlays, bridges
and dentures that are or can be made
serviceable.
22. Preventive restorations in the absence of dental
disease.
23. Periodontal splinting of teeth by any method.
24. For duplicate dentures, prosthetic devices or any
other duplicative device.
25. For services determined to be furnished as a
result of a prohibited referral. “Prohibited
referral” means a referral prohibited by Section
1-302 of the Health Occupations Article.
Prohibited referrals are referrals of a patient to
an entity in which the referring dentist, or the
dentist’s immediate family: (a) owns a beneficial
interest; or (b) has a compensation
arrangement. The dentist’s immediate family
includes the spouse, child, child’s spouse,
parent, spouse’s parent, sibling, or sibling’s
spouse of the dentist, or that dentist in
combination.
26. For which in the absence of insurance the
Member would incur no charge.
27. For plaque control programs, oral hygiene, and
dietary instructions.
MD (01/14)
— 7 —
STMD (01/14)
29. For training and/or appliance to correct or control
harmful habits, including, but not limited to,
muscle training therapy (myofunctional therapy).
30. For any claims submitted to the Company by the
Member or on behalf of the Member in excess of
twelve (12) months after the date of service.
Failure to furnish the claim within the time
required does not invalidate or reduce a claim if it
was not reasonably possible to submit the claim
within the required time, if the claim is furnished
as soon as reasonably possible and, except in the
absence of legal capacity of the Member, not later
than 1 year from the time claim is otherwise
required.
31. Which are not Dentally Necessary as determined
by the Company.
MD (01/14)
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20
EOC (revision 10/22/14)
LIMITATIONS -– DPPO Plan
The following services will be subject to limitations as set forth below:
1. Full mouth x-rays – one every five years.
2. One set(s) of bitewing x-rays per six months
through age thirteen, and one set(s) of
bitewing x-rays per twelve months for age
fourteen and older.
3. Periodic oral evaluation – two per benefit
accumulation period.
4. Prophylaxis – two per benefit accumulation
period. One (1) additional for Participants
under the care of a medical professional
during pregnancy.
5. Fluoride treatment – two per benefit
accumulation period through age eighteen
(18).
6. Space maintainers - only eligible for
Participants through age eighteen when used
to maintain space as a result of prematurely
lost deciduous molars and permanent first
molars, or deciduous molars and permanent
first molars that have not, or will not develop.
7. Prefabricated stainless steel crowns - one per
tooth per lifetime for Participants under age
fourteen.
8. Crown lengthening - one per tooth per lifetime.
9. Periodontal maintenance following active
periodontal therapy – two per calendar year in
addition to routine prophylaxis.
10. Periodontal scaling and root planing - one per
two year period per area of the mouth.
11. Replacement of an existing:
filling with another filling – not within 12
months of placement.
single crown with another single crown -
not within five years of placement.
inlay with another inlay, or with a single
crown or
onlay – not within five years of placement.
onlay with another onlay, or with a single
crown -
not within five years of placement.
buildup with another buildup - not within
five years of placement.
post and core with another post and core
- not within five years of placement.
12. Replacement of natural tooth/teeth in an arch –
not within five years of placement of a fixed
partial denture, full denture or partial removable
denture.
13. Placement or replacement of single crowns,
inlays, onlays, single and abutment buildups and
post and cores, bridges, full and partial dentures
– one within five years of their placement.
14. Denture relining, rebasing or adjustments - are
included in the denture charges if provided
within six months of insertion by the same
dentist.
15. Subsequent denture relining or rebasing –
limited to one every three year(s) thereafter.
16. Surgical periodontal procedures - one per two
year period per area of the mouth.
17. Sealants - one per tooth per three year(s)
through age fifteen on permanent first and
second molars.
18. Pulpal therapy - through age five on primary
anterior teeth and through age eleven on
primary posterior molars.
19. Root canal treatment and retreatment – one per
tooth per lifetime.
20. Recementations by the same dentist who
initially inserted the crown or bridge during the
first twelve months are included in the crown or
bridge benefit, then one per twelve months
thereafter; one per twelve months for other than
the dentist who initially inserted the crown or
bridge.
21. Contiguous surface posterior restorations not
involving the occlusal surface will be payable as
one surface restoration.
22. Posts are only covered as part of a post buildup.
23. An Alternate Benefit Provision (ABP) will be
applied 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.
MD (01/14)
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Current Dental Terminology ©2021 American Dental Association. All rights reserved.
Rider to Schedule of Benefits and Schedule of Exclusions and Limitations
Implantology
This Rider is effective on January 1, 2015 and is attached to and made a part of the Schedule of Benefits and
Schedule of Exclusions and Limitations.
SCHEDULE OF BENEFITS
The Company will pay implantology benefits for eligible Plan participants and enrolled dependents for the
following Covered Services equal to 50% of the Maximum Allowable Charge as determined by United Concordia.
Implantology Services
Surgical Services
D6010 surgical placement of implant body: endosteal implant
D6011 second stage implant surgery.
D6013 surgical placement of mini implant; claims review includes a review of radiographs and an indication of how
the implants will be restored
D6040 surgical placement: eposteal implant
D6050 surgical placement: transosteal implant
D6100 implant removal, by report
D6101 debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the
exposed implant surfaces, including flap entry and closure
D6102 debridement and osseous contouring of a periimplant defect or defects surrounding a single implant,
and includes surface cleaning of the exposed implant surfaces including flap entry and closure
D6104 bone graft at time of implant placement
D7994 surgical placement: zygomatic implant
Supporting Structures
D6055 connecting bar – implant supported or abutment
D6056 prefabricated abutment – includes modification and placement
D6057 custom fabricated abutment – includes placement
Implant/Abutment Supported Removable Dentures
D6110 implant/abutment supported removable denture for edentulous arch – maxillary
D6111 implant /abutment supported removable denture for edentulous arch – mandibular
D6112 implant/abutment supported removable denture for partially edentulous arch – maxillary
D6113 implant/abutment supported removable denture for partially edentulous arch – mandibular
D6114 implant/abutment supported fixed denture for edentulous arch – maxillary
D6115 implant/abutment supported fixed denture for edentulous arch – mandibular
D6116 implant/abutment supported fixed denture for partially edentulous arch – maxillary
D6117 implant/abutment supported fixed denture for partially edentulous arch – mandibular
Single Crowns, Abutment Supported
D6058 abutment supported porcelain/ceramic crown
D6059 abutment supported porcelain fused to metal crown (high noble metal)
D6060 abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 abutment supported porcelain fused to metal crown (noble metal)
D6062 abutment supported cast metal crown (high noble metal)
D6063 abutment supported cast metal crown (predominantly base metal)
D6064 abutment supported cast metal crown (noble metal)
D6094 abutment supported crown – (titanium)
D6097 abutment supported crown-porcelain fused to titanium and titanium alloys
Single Crowns, Implant Supported
D6065 implant supported porcelain/ceramic crown
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal)
— 10 —
Current Dental Terminology ©2021 American Dental Association. All rights reserved.
Rider to Schedule of Benefits and Schedule of Exclusions and Limitations
Implantology
This Rider is effective on January 1, 2015 and is attached to and made a part of the Schedule of Benefits and
Schedule of Exclusions and Limitations.
SCHEDULE OF BENEFITS
The Company will pay implantology benefits for eligible Plan participants and enrolled dependents for the
following Covered Services equal to 50% of the Maximum Allowable Charge as determined by United Concordia.
Implantology Services
Surgical Services
D6010 surgical placement of implant body: endosteal implant
D6011 second stage implant surgery.
D6013 surgical placement of mini implant; claims review includes a review of radiographs and an indication of how
the implants will be restored
D6040 surgical placement: eposteal implant
D6050 surgical placement: transosteal implant
D6100 implant removal, by report
D6101 debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the
exposed implant surfaces, including flap entry and closure
D6102 debridement and osseous contouring of a periimplant defect or defects surrounding a single implant,
and includes surface cleaning of the exposed implant surfaces including flap entry and closure
D6104 bone graft at time of implant placement
D7994 surgical placement: zygomatic implant
Supporting Structures
D6055 connecting bar – implant supported or abutment
D6056 prefabricated abutment – includes modification and placement
D6057 custom fabricated abutment – includes placement
Implant/Abutment Supported Removable Dentures
D6110 implant/abutment supported removable denture for edentulous arch – maxillary
D6111 implant /abutment supported removable denture for edentulous arch – mandibular
D6112 implant/abutment supported removable denture for partially edentulous arch – maxillary
D6113 implant/abutment supported removable denture for partially edentulous arch – mandibular
D6114 implant/abutment supported fixed denture for edentulous arch – maxillary
D6115 implant/abutment supported fixed denture for edentulous arch – mandibular
D6116 implant/abutment supported fixed denture for partially edentulous arch – maxillary
D6117 implant/abutment supported fixed denture for partially edentulous arch – mandibular
Single Crowns, Abutment Supported
D6058 abutment supported porcelain/ceramic crown
D6059 abutment supported porcelain fused to metal crown (high noble metal)
D6060 abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 abutment supported porcelain fused to metal crown (noble metal)
D6062 abutment supported cast metal crown (high noble metal)
D6063 abutment supported cast metal crown (predominantly base metal)
D6064 abutment supported cast metal crown (noble metal)
D6094 abutment supported crown – (titanium)
D6097 abutment supported crown-porcelain fused to titanium and titanium alloys
Single Crowns, Implant Supported
D6065 implant supported porcelain/ceramic crown
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal)
Current Dental Terminology ©2021 American Dental Association. All rights reserved.
Fixed Partial Denture, Abutment Supported
D6068 abutment supported retainer for porcelain/ceramic FPD
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 abutment supported retainer for cast metal FPD (high noble metal)
D6073 abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 abutment supported retainer for cast metal FPD (noble metal)
D6194 abutment supported retainer crown for FPD – (titanium)
D6195 abutment supported retainer-porcelain fused to titanium and titanium alloys
Fixed Partial Denture, Implant Supported
D6075 implant supported retainer for ceramic FPD
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble
metal)
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
D6082 implant supported crown-porcelain fused to predominantly base alloys
D6083 implant supported crown-porcelain fused to noble alloys
D6084 implant supported crown-porcelain fused to titanium and titanium alloys
D6086 implant supported crown-predominantly base alloys
D6087 implant supported crown-noble alloys
D6088 implant supported crown-titanium and titanium alloys
D6098 implant supported retainer-porcelain fused to predominantly base alloys
D6099 implant supported retainer-for FPD porcelain fused to noble alloys
D6120 implant supported retainer porcelain fused to titanium and titanium alloys
D6121 implant supported retainer for metal FPD- predominantly base alloys
D6122 implant supported retainer for metal FPD-noble alloys
D6123 implant supported retainer for metal FPD-titanium and titanium alloys
Other Repair Procedures
D7950 osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous or nonautogenous,
by report
D7951 sinus augmentation with bone or bone substitutes via a lateral open approach
D7952 sinus augmentation via a vertical approach
D7953 bone replacement graft for ridge preservation – per site
Deductible(s)
Deductible will be applied to implantology services.
Maximum(s)
The annual Maximum indicated on the Schedule of Benefits will be applied to implantology services.
Waiting Period(s)
No Waiting Period will be applied to implantology services.
SCHEDULE OF EXCLUSIONS AND LIMITATIONS
The Schedule of Exclusions and Limitations is amended as follows:
Exclusions
Any exclusions relating to implantology services are deleted.
Limitations
The following limitation does not apply to the above listed implantology procedures:
An alternate benefit provision (ABP) will be applied if a covered dental condition can be treated by means of a
professionally acceptable procedure which is less costly than the treatment recommended by the dentist.
The following limitations are added to the Schedule of Exclusions and Limitations:
Implantology services are limited to one (1) per tooth per lifetime.
Implantology services are limited to participants age eighteen (18) and older.
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Current Dental Terminology ©2021 American Dental Association. All rights reserved.
Rider to Schedule of Benefits and Schedule of Exclusions and Limitations
Implantology
This Rider is effective on January 1, 2015 and is attached to and made a part of the Schedule of Benefits and
Schedule of Exclusions and Limitations.
SCHEDULE OF BENEFITS
The Company will pay implantology benefits for eligible Plan participants and enrolled dependents for the
following Covered Services equal to 50% of the Maximum Allowable Charge as determined by United Concordia.
Implantology Services
Surgical Services
D6010 surgical placement of implant body: endosteal implant
D6011 second stage implant surgery.
D6013 surgical placement of mini implant; claims review includes a review of radiographs and an indication of how
the implants will be restored
D6040 surgical placement: eposteal implant
D6050 surgical placement: transosteal implant
D6100 implant removal, by report
D6101 debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the
exposed implant surfaces, including flap entry and closure
D6102 debridement and osseous contouring of a periimplant defect or defects surrounding a single implant,
and includes surface cleaning of the exposed implant surfaces including flap entry and closure
D6104 bone graft at time of implant placement
D7994 surgical placement: zygomatic implant
Supporting Structures
D6055 connecting bar – implant supported or abutment
D6056 prefabricated abutment – includes modification and placement
D6057 custom fabricated abutment – includes placement
Implant/Abutment Supported Removable Dentures
D6110 implant/abutment supported removable denture for edentulous arch – maxillary
D6111 implant /abutment supported removable denture for edentulous arch – mandibular
D6112 implant/abutment supported removable denture for partially edentulous arch – maxillary
D6113 implant/abutment supported removable denture for partially edentulous arch – mandibular
D6114 implant/abutment supported fixed denture for edentulous arch – maxillary
D6115 implant/abutment supported fixed denture for edentulous arch – mandibular
D6116 implant/abutment supported fixed denture for partially edentulous arch – maxillary
D6117 implant/abutment supported fixed denture for partially edentulous arch – mandibular
Single Crowns, Abutment Supported
D6058 abutment supported porcelain/ceramic crown
D6059 abutment supported porcelain fused to metal crown (high noble metal)
D6060 abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 abutment supported porcelain fused to metal crown (noble metal)
D6062 abutment supported cast metal crown (high noble metal)
D6063 abutment supported cast metal crown (predominantly base metal)
D6064 abutment supported cast metal crown (noble metal)
D6094 abutment supported crown – (titanium)
D6097 abutment supported crown-porcelain fused to titanium and titanium alloys
Single Crowns, Implant Supported
D6065 implant supported porcelain/ceramic crown
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal)
United Concordia DPPO Benefit Features
Preventive Incentive®
With Preventive Incentive, all Class I Diagnostic and
Preventive services—such as cleanings, exams, x-rays and
more—do not count toward your annual maximum.
The Smile for Health® Maternity Dental Benefit
This benefit provides pregnant women with an additional
dental cleaning during pregnancy. The extra cleaning can
help prevent periodontal (gum) disease, which has been
linked to premature and low-birthweight babies, as well as
help control pregnancy gingivitis.
Online Tools
Dental Health Center
In the Dental Health Center on www.UnitedConcordia.com, you can find dental-health
educational information including articles, brochures, videos and much more.
MyDentalBenefits
Review benefits information any time in MyDentalBenefits on
www.UnitedConcordia.com/statemd:
• Select MyDentalBenefits on the left side of the page
• Register or sign in with your user ID and password
• Access personalized information, including:
– Eligibility
– Benefits
– Maximums and deductible status
– Claim status
– Procedure history
– Explanations of benefits (EOBs)
PPO Members
Beginning February 1, 2012, for all claims that are covered in full, you will no longer receive an
Explanation of Benefits (EOB) in the mail from United Concordia, but you can access all of your
EOBs online, any time. For all claims not covered in full or if we owe you a reimbursement, you
will continue to receive an EOB in the mail.
UnitedConcordia.com • 1-888-638-3384
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Custom Mobile App
Enjoy Enhanced Benefits with our Advantage Plus Network
United Concordia is a national company with resources and an understanding of your local dentist
market. We carefully screen and qualify dentists in our network to ensure you get the best oral care.
Enhanced Network Benefits
Our Advantage Plus network gives you access to over 81,000 in-network dentists and specialists at
over 295,000 access points nationwide. Chances are you’ll find at least two dentists within 10 miles
of where you live or work.
Save More with a Network Dentist—Savings Example
1
Check out why visiting a network dentist benefits your smile and your wallet!
Online and Personal Service
We offer a variety of tools that make handling your benefits easy:
• MyDentalBenefits: Create an online account at UnitedConcordia.com in the Member Sign In area
to view your eligibility information, claim status, print ID cards and more!
• Find a Dentist: Visit UnitedConcordia.com to search by specialty, zip code or network.
• Custom Mobile App: Access your benefit information and virtual ID card. Download it for FREE at
Google Play or the App Store (search for “United Concordia”).
Member’s Annual
Dental Care
Example
Dentist
Charge
Network Dentist
Visit—Member
Responsibility
2
Non-network
Dentist Visit—
Member Responsibility
Member’s Savings
for
Visiting an Advantage
Plus Network Dentist
2 Cleanings $176 $0 $66 $66
2 Exams $100 $0 $43 $43
1 Set x-rays $131 $0 $51 $51
2 Composite fillings $278 $32 $137 $104
1 Crown $1,082 $347 $712 $366
TOTAL $1,767 $379 $1,009 $630
1. All services performed by an Advantage Plus Network dentist.
Directions to download:
• Download the United Concordia app
• After download launch the app
• Select “I am a State of Maryland Employee” in
Select Your Settings screen
• Confirm that you are a State of Maryland employee
UnitedConcordia.com • 1-888-638-3384
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Manage Your Benefits Online With MyDentalBenefits
Create Your Account (be sure you have your insurance card handy!)
• Go to UnitedConcordia.com/statemd
• Click MyDentalBenefits
• Enter the ID number found on your insurance card and your birthday
• Provide basic account registration information
• Confirm your account creation
MyDentalBenefits Provides You Access to:
• Check claim status and payments
• Monitor deductibles and maximums
• Print ID cards
• Sign up for paperless EOBs
Find a Dentist Search Tool
In a hurry and just need to find a dentist? Our search tool allows you to find network specialist,
narrow providers by zip code, or confirm if your current provider is in your network. Start your
search at UnitedConcordia.com/statemd.
Your network also includes access to dentists who can save you even more money!
That’s because even though our entire network of dentists accepts our allowances
for services that are covered, each dentist with a green $ave! box next to his/her
name accepts our allowances for non-covered* services as well. These include services that go
over your $2,500 annual maximum. Regardless of which dentist you see, you are still responsible
for deductibles and coinsurance payments, as applicable.
Award-Winning Customer Service
Call 1-888-638-3384 to speak to dental professionals and get benefits information.
• Tenured, US-based representatives with specialized knowledge
• Live 24/7 dedicated customer service
• 97% of calls resolved on first attempt
Smartphone Apps
Download our FREE apps on the App Store or Google Play. Just search for “United Concordia.”
Custom Member App—Fast, secure, on-the-go access
• Access your benefits information from anywhere
• Find a dentist near you
• View and use a virtual United Concordia ID card
Chomper Chums™ App for Kids Age 4–11
• Develop proper brushing habits
• Up to two-minute adjustable brushing timer
• Fun game characters
*Discount arrangements are available where allowed by law. Non-covered services in which no benefit payments, including alternate benefit
payments, are made by United Concordia, and may vary by plan design. Discount levels may vary by procedure and geographic area.
UnitedConcordia.com • 1-888-638-3384
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EEM-0087-0920
