state of connecticut

How to Use the UnitedHealthcare Basic Dental Plan
and this Dentist Listing

This Listing was compiled to assist State of Connecticut Employees and Retirees enrolled in the UnitedHealthcare Basic Dental Plan, in choosing a dentist. In the Basic Dental Plan, participants may use any dentist, including any dentist not listed here.

The Dentists listed in this directory, based on a review of their past billing practices, do not charge more than allowed amounts. That is, while they charge the patient any applicable copayment for covered services, their history has been not to seek additional payment from the patient for such services by charging higher than the total allowable amount (the amount paid by UnitedHealthcare Dental, plus the co-payment), and then billing the patient for the balance. UnitedHealthCare will accept electronic billing directly from any dentist.

Any employee choosing a dentist in this directory who bills for such balance (that is, bills beyond any applicable co-payment) should contact UnitedHealthcare Dental at 1-800-896-4834 so that appropriate action may be taken to correct the problem. Dentists who insist on balance billing will be removed from the Basic Dental Plan directory.

This listing can be used to locate a dentist if you or your enrolled family members do not have a regular dentist, or if you need to change dentists. It can also be used to determine if your regular dentist's charges are within the Plan allowed amount. After choosing a dentist from this list, call the dentist's office to make an appointment. If you cannot find a dentist near you on this list, you may choose any dentist.

After the initial dental exam, if the dentist determines that you or an enrolled family member requires extensive non-emergency dental work, you should discuss the course of treatment and the total cost with the dentist. You can then request that the dentist send a pre-treatment estimate to UnitedHealthcare Dental. UnitedHealthcare Dental will send back to the dentist a detailed schedule showing the plan allowance, the plan payment, and your co-payment for the services. You can then make an informed decision with the dentist before obtaining the services.

If you are enrolling in State of Connecticut Dental coverage for the first time (such as a new hire), and either do not have a dentist, or if your regular dentist is a contracted dentist (asterisk), you may wish to enroll in the UnitedHealthcare Enhanced Dental Plan instead of the Basic plan. The Enhanced Dental Plan provides coverage for more services and with lower copayments. Note that newly hired employees have thirty (30) days from the date of hire to enroll in coverage.

Dentists wishing to be added to this list should contact UnitedHealthcare Dental at 1-800-822-5353.

UnitedHealthcare Dental® dental plan
Basic Plan/covered dental services P3127

 

   
Individual Annual Deductible $0
Family Annual Deductible $0
Annual Maximum Benefit None, except for periodontics maximum of $500 per person per calendar year

Annual deductible applies to preventive and diagnostic services Not applicable
Waiting Period No waiting period

COVERED SERVICES* PLAN PAYS** BENEFIT GUIDELINES
PREVENTIVE AND DIAGNOSTIC DENTAL SERVICES
Periodic Oral Examinations 80% Limited to 2 times per calendar year.
Bite-Wing X-rays 80% Limited to one series of films per calendar year.
Complete Series or Panorex X-rays 80% Limited to one time per consecutive 36 months.
Dental Prophylaxis (Cleanings) 80% Limited to 2 times per calendar year.
Fluoride Treatments 80% Limited to covered persons under the age of 19 years, and limited to 2 times per calendar year.
Sealants 0% Not covered.
BASIC DENTAL SERVICES
Space Maintainers 67% Limited to covered persons under the age of 19 years, only for premature loss of teeth.
Palliative Treatment (Relief of Pain) 80% Covered as a separate benefit only if no other service, other than X-rays and exam, wereperformed on the same tooth during the visit.
General Anesthesia 0% Not covered.
Amalgam Restorations (Fillings) 80% One restoration allowed per surface every consecutive 12 months.
Composite Restorations (Fillings) 80% One restoration allowed per surface every consecutive 12 months. For anterior teeth only.
Simple Extraction 80%
Surgical Extraction including Impacted Wisdom Teeth 67%
Root Canal Treatment 80%
Scaling and Root Planing 50%
Periodontal Surgery 50% Limited to once every consecutive 36 months per surgical area.
Periodontal Maintenance 80% Limited to 2 times per calendar year, not in addition to dental prophylaxis.
MAJOR DENTAL SERVICES
Crowns, Inlays, and Onlays 67% Limited to one time per tooth per consecutive 60 months.
Fixed Bridges 0% Not covered.
Full Dentures 0% Not covered.
Partial Dentures 0% Not covered.
Recement Bridges, Crowns, Inlays 80% Limited to once every consecutive 6 months per restoration.
Relining and Rebasing Dentures 80% Limited to one time every consecutive 24 months, and limited to after the 12 month period following initial insertion.
Repairs to Full Dentures, Partial Dentures, Bridges 80% Limited to repairs or adjustments performed more than 12 months after the initial insertion, and limited to once per consecutive 12 months.


* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $200; please consult your dentist.

** The percentage of benefits is based on the schedule of reasonable and customary charges in the geographic area in which the expenses are incurred.

The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the Certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.

UnitedHealthcare Dental® Indemnity Plan is either underwritten or provided by: United HealthCare Insurance Company, Hartford, Connecticut; United HealthCare Insurance Company of New York, Hauppauge, New York; or United HealthCare Services, Inc.

11/06 ©2006 United HealthCare Services, Inc.

UnitedHealthcare/dental exclusions and limitations

GENERAL LIMITATIONS

ORAL EXAMINATIONS Covered as a separate benefit only if no other service was performed during the visit other than prophylaxis and X-rays. Comprehensive oral exam limited to 1 per consecutive 36 months. Periodic oral exams limited to 2 per calendar year.

COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to one time per consecutive 36 months.

BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.

EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.

DENTAL PROPHYLAXIS Limited to 2 times per calendar year. Periodontal maintenance can be substituted for a dental prophylaxis/cleaning.

FLUORIDE TREATMENTS Limited to covered persons under the age of 19 years, and limited to 2 times per calendar year. Treatment should be done in conjunction with dental prophylaxis.

SPACE MAINTAINERS Limited to covered persons under the age of 19 years, once per lifetime, only for premature loss of teeth. Benefit includes all adjustment within 6 months of installation.

RESTORATIONS Multiple restorations on one surface will be treated as a single filling. Limited to 1 tooth surface per consecutive 12 months. Composite restorations limited to anterior teeth only.

PIN RETENTION Limited to 2 pins per tooth; not covered in addition to Cast Restoration.

INLAYS AND ONLAYS Limited to one time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

CROWNS Limited to one time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. Stainless steel crowns limited to primary teeth only.

SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

APICOECTOMY Limited to 1 per tooth per lifetime.

PERIODONTAL MAINTENANCE Limited to 2 per calendar year. Periodontal Maintenance is not in addition to dental prophylaxis.

RELINING AND REBASING DENTURES Limited to relining or rebasing performed more than 12 months after the initial insertions. Limited to 1 time per consecutive 24 months.
REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES

Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 time per consecutive 12 months after.

PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

FULL MOUTH DEBRIDEMENT Limited to once every consecutive 36 months.

GENERAL EXCLUSIONS

The following are not covered:

1. Dental Services that are not necessary.

2. Hospitalization or other facility charges.

3. Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

4. Reconstructive Surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.

5. Any dental procedure not directly associated with dental disease.

6. Any procedure not performed in a dental setting.

7. Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

8. Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

9. Expenses for dental procedures begun prior to the Covered Person's eligibility with the Plan.

10. Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.

11. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.

12. Replacement of missing natural teeth lost prior to the onset of plan coverage.

13. Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.

14. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

15. Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

16. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

17. Placement of dental implants, implant-supported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.

18. Placement of fixed bridgework solely for the purpose of achieving periodontal stability.

19. Billing for incision and drainage if the involved abscessed tooth is removed on the same date of service.

20. Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal. Treatment of congenital malformations of hard or soft tissue, including excision.

21. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

22. Acupuncture; acupressure and other forms of alternative treatment.

23.. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

24. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

25. Diagnostic casts.

26. Sealants.

27. Posts and cores.

28. Bridge work and full or partial dentures.

29. Occlusal guards.

30. General Anesthesia, Analgesia, IV Sedation, and Desensitizing Medicment.

31. Bacteriologic Cultures.

32. Apexification, Hemisection, and Root Resection/ Amputation.

33. Provisional Splinting.

34. Alveoloplasty, Biopsy, Frenectomy, Incision and Drainage, Removal of Benign Cysts, and Removal of Exotosis.

35. Occlusal adjustments.

36. Removal of exostosis.

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