How the Dental
PPO Plan Works
Dental PPO Plan (effective 1/1/01) - The Dental Participating Provider Option Plan allows you to obtain services either from a network dentist or from any dentist you choose. See the Important Numbers and Web Sites section of this handbook for more information.
If you choose a Dental PPO Provider, you have the benefit of reduced out-of-pocket expenses. However, if you choose a licensed dentist who is not part of the Dental PPO network, the plan reimburses a percentage of eligible expenses based on the Dental PPO payment rates.
The PPO Plan pays for eligible dental benefits based on the Dental PPO allowance. The plan will not pay:
any amount incurred that is more than the
PPO allowance in the geographic location where the expenses
are incurred as initially determined by the Claims
Administrator, subject to the appeals procedure; or
for a service or supply that is not
generally accepted in dental practice or not needed for the
treatment or diagnosis of a dental condition.
Maximum Benefit
The maximum benefit is $1200 for each covered person in a benefit year.
Benefit Year
The benefit year is the calendar year, January 1st through December 31st . For new employees, your first benefit year is the effective date of your coverage through December 31st . After that, your benefit year is the calendar year, January 1st through December 31st .
In Network
Deductible
The deductible is the portion of your dental expenses that you pay each calendar year before the plan pays benefits. The annual deductible for the Dental PPO Plan is $50 for each covered person in a calendar year. However, the deductible does not apply to eligible diagnostic and preventive services.
Co-payment
After you have paid the calendar year deductible, the plan will pay a percentage of your eligible expenses based on the Dental PPO allowance. You will be responsible for the remaining balance. This feature is called the co-payment.
The amount of the co-payment depends on the type of expense you incur. See the Dental Comparison Chart on page PPOD-1A of this handbook for more co-payment information.
The dentist cannot charge you the difference between the Dental PPO allowance and the billed charge for an eligible service if you obtain services from a network dentist.
Out-of-Network
Deductible
There is a $100 calendar year deductible if you obtain services from a licensed dentist who is not part of the Dental PPO plan network.
Co-payment
After you have paid the calendar year deductible, the plan pays 80% of the PPO allowance for eligible preventive and diagnostic services (after the deductible) and 50% of the PPO allowance for other eligible services. Remember, the plan pays a higher percentage of the PPO allowance if you obtain services from a network dentist.
What the PPO Plan Covers
Diagnostic and Preventive Services - in network
The PPO Plan pays 100% of the PPO allowance fees, with no deductible, for the following diagnostic and preventive services:
oral exams - two exams in a benefit year;
emergency treatment for the relief of
dental pain (does not include restoration);
full mouth x-rays on an initial visit or
once every 36 months;
supplemental bitewing x-rays twice in a
benefit year;
prophylaxis - teeth cleaning twice in a
benefit year; and
fluoride treatment under age 14
Other Services
Other eligible in-network services are covered at the PPO allowance after you have met your deductible. Eligible services include:
silver amalgam, silicate, plastic and
composite restoration fillings and restorative bonding
(retrograde fillings are included);
endodontics (root canal therapy) for
diagnosis, prevention and treatment of the dental pulp,
including root canal therapy, pulp capping and pulpotomy;
prosthodontics including inlays, onlays,
crowns, bridge work and removable dentures, including
rebasing (replacement of an existing appliance will not be
covered unless the appliance is at least five years old);
periodontics for treatment of diseases of
the gums and tissues supporting the teeth, including gingival
curettage, gingivectomy, bone surgery and management of acute
gum infection; and dental treatment for temporomandibular joint
(TMJ) disorders subject to all other limits and exclusions of
the plan.
What the Dental PPO Plan Doesn't Cover
Although the plan covers many of your dental care needs, there are some dental services that are not covered, such as:
hospitalization for any dental procedure;
home visits;
hospital bedside visits;
hospital-administered anesthesia;
experimental procedures;
implantation;
pharmacological regimens;
prescription or over-the-counter
medications;
convenience and personal items;
the setting of fractures or dislocation;
treatment of malignancies, cysts or
neoplasms;
services which, in the opinion of the
attending dentist, are not necessary for the patient's
dental health;
missed appointment fees;
orthodontic work in progress;
any items covered under the Medical Plan;
services covered by Workers'
Compensation or employer's liability laws;
services provided to the member, without
cost, by any municipality, county or other political
subdivision, other than Medicaid services;
dental services with respect to congenital
malformations or primarily for cosmetic or aesthetic
purposes, except where such services are within the scope of
benefits;
any services, treatment or supplies which
are not reasonably necessary for the care and treatment of a
person;
orthodontic treatment including, but not
limited to, removable and fixed appliances, pre-orthodontic
treatment and orthodontic retention;
separate laboratory charges when not
included and billed by the dentist;
dental services received from a dental or
medical department maintained by or on behalf of an employer,
a mutual benefit association, labor union, trustees or
similar person or group;
dental services rendered or supplies
furnished after the termination date of the person's
Dental PPO Plan coverage;
dental services for which coverage is
available to the person, in whole or in part, under a medical
plan;
sealants (except for back molars);
mouth rehabilitation where the obligation
of the dental plan administrator will be to cover only those
benefits appropriate to those procedures necessary to
eliminate oral disease and replace missing teeth; the balance
of the treatment including cost to increase vertical
dimension or restore the occlusion will remain the
responsibility of the patient;
initial placement of a full or partial
denture or bridge replacing teeth extracted prior to the
effective date of the policy:
bruxism appliances, mouthguards, occlusal
guards or bite plates; and
anything not listed as a covered service.
Filing Claims
To obtain benefits under the Dental PPO Plan, you must submit a claim. While many dentists will file a claim for you, it is your responsibility to make sure that the necessary claim information has been provided.
How to File a Claim
Before your dental appointment, request a City of Chicago Dental Insurance Claim Form from your Department's Benefit Liaison or the Benefits Management Office and follow these instructions:
1) Complete the front side of the claim form. Be sure to answer all questions completely and sign the form.
2) If you want the payment mailed directly to your dentist, sign the back of the claim form.
3) Ask your dentist to complete and sign the back side of the claim form indicating what type of work was performed and the charge for each procedure.
4) Attach all appropriate itemized dental bills or payment receipts.
5) Mail the form. (See the Important Numbers and Web site section of this handbook for more claim administrator information.)
After the claim has been processed, the benefit payment will be sent to your dentist. All claims must be filed with the dental vendor within two years of the date that services were rendered or they will not be eligible for payment.
Coordination of Benefits (COB)
Some individuals have dental care coverage in addition to this plan. For example, you may be covered as a dependent under your spouse's dental plan.
The City's Dental PPO Plan works with other group plans to reimburse up to 100% of the allowable expenses for you and your dependents. An allowable expense is any expense covered at least in part by this plan. The maximum payable by the plan is limited to the amount that would have been paid if there was no other plan involved.
How COB Works
Here's how benefits are coordinated when a claim is made:
the primary plan pays benefits first
without regard to any other plan; and
the secondary plan adjusts its payments so
that the total benefit paid will not be greater than your
allowable expense.
A plan without a coordinating provision is always the primary plan. If all plans have a coordinating provision, here's how benefit payments will be determined:
The plan covering the patient directly,
rather than as a dependent, will be the primary plan.
If a child is covered under both
parents' plans, the plan covering the parent whose
birthday comes first in a calendar year is the primary plan.
If both parents have the same birthday, the plan of the
parent who has been covered longer is the primary plan. If
the other plan does not have this rule but has a rule based
on the gender of the parent, then the rule of the other plan
will determine the order of benefits.
If you are separated or divorced, the
order will be as follows:
- if the court has established one parent as financially responsible for the child's health care, the plan of the parent with that responsibility is primary; then
- the plan of the parent with custody of the child; then
- the plan of the step-parent married to the parent with custody of the child; then - the plan of the parent that does not have custody of the child.
The City's plan will pay the benefits explained in this section of the handbook when this plan is the primary plan. When this plan is the secondary or later plan, it will usually pay the difference between benefits paid from the primary plan and the benefits provided by this plan. However, the total benefits paid will not be more than what would have been paid if this plan were primary.
Benefits are coordinated between dental plans in the following situations:
you are enrolled in the Dental HMO Plan as
your primary plan and your other plan is PPO or an indemnity
plan, or
you are enrolled in the Dental PPO plan
and your other plan is a PPO or also an indemnity plan.
If a Claim is Denied (Appeal Procedure)
If your eligibility for benefits or if all or part of your claim is denied, you have the right to challenge the decision by sending a written request for review to the claims administrator. See the Important Numbers and Web Sites section of this handbook for more claim administrator information.
If you have filed an appeal with your plan's claims administrator and you are not satisfied with the decision, you can appeal the decision by sending a written request for review to the City of Chicago Benefits Manager.
The Benefits Manager will review the claim and notify you of a denial within five business days after the denial of eligibility or claim. You can appeal the denial by submitting a written request to the Benefits Committee no later than 30 calendar days after the notice of denial by the Benefits Management Office. Your written request must state why you think your claim should not have been denied. You must include all supporting dental or eligibility documentation.
The Benefits Committee members include the Budget Director, the City Comptroller, the Commissioner of Personnel, the Benefits Manager and the Chairman of the Committee on Finance, or whomever they designate.
Correspondence with the Committee should be addressed to:
City of Chicago
The Department of Finance
Benefits Division
333 South State Street, Room 400
Chicago, IL 60604-3978
Attn: Benefits Committee
Your appeal will be reviewed and you will usually be notified of the results of this review within 60 days.
November 2002