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Hosmed Dental Benefit Guide 2010

  1. Pre-authorization
  2. Benefit Exclusion
  3. Orthodontics
  4. Periodontics
  5. Hospitalization
  6. Dental Therapist Guideline
  7. Hosmed Dental Benefit Table
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PRE-AUTHORIZATION

Pre-authorization is required for treatment listed below:

  1. Periodontics
  2. Orthodontics
  3. Crown and bridgework
  4. Chrome cobalt dentures
  5. Hospitalization

Note:
Cover is subject to Hosmed benefit protocols and rules. If pre- authorization has not been received and authorized prior to treatment, no payment will be processed. Members must check the option they are on to confirm benefits (See Dental benefit table below)
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BENEFIT EXCLUSION

The following treatment is not covered. The member is liable for the total cost of these procedures.

  • Oral hygiene instructions
  • Professionally applied topical fluoride in adults
  • Fissure sealants on patients older than 18 years
  • Root canal treatment on third molars
  • Pulping capping (direct)
  • Metal base to full dentures
  • Dental bleaching and porcelain veneers
  • Crowns on third molars (wisdom teeth)
  • Pontics on second molars
  • Crowns used to repair teeth damaged due to bruxism erosion or fluorosis
  • Crowns used to restore teeth for cosmetic reasons
  • Fixed prosthodontics (crowns) where a reasonable attempt has not been made to restore/replace the tooth conservatively
  • Fixed prosthodontics (crowns) where the members mouth is periodontallly compromised
  • Crowns where the tooth has been recently restored to function
  • Gingivectomy
  • Periodontal flap surgery and tissue grafting
  • Perio Chip
  • Orthodontic re-treatment
  • Implantology
  • Orthognathic (jaw correction) surgery and related hospital costs
  • Dentectomies in hospital
  • Frenectomies in hospital
  • Implantation and associated surgical procedures in hospital
  • Fillings : extractions and root canal therapy for adults in hospital
  • Sinus lifts
  • Cost of implant components
  • High impact acrylic
  • Cost of bone regeneration material
  • Fixed prosthodontics used to restore teeth for cosmetic reasons
  • Orthodontics to align teeth for cosmetic reasons
  • Cost of gold, precious,or semi precious metal
  • Full series Peri-apical X-rays (8108)
  • Metal , porcelain, or resin inlays
  • Bone augmentation, or tissue regeneration
  • Treatment of attrition

    • In the event of a dispute regarding exclusions and benefits, the rules of Hosmed will prevail.
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    ORTHODONTICS

    Orthodontic benefits apply to functional treatment only.

    The following information must be sent through to:
    Hosmed Orthodontics department, Tel: 011 290 6384

    The following information must be provided:

    1. Panoramic X- Ray
    2. Celphalemetric X-Ray and tracing
    3. Pre treatment photographs
    4. Study models (if called for)
    5. Completed orthodontic authorization forms obtained from Hosmed indicating full treatment plan
    6. Estimated time in theatre
    7. 72 hours notice prior to procedure

    Once approved payment will be paid as an initial deposit, and the balance over an estimated time period. Payment paid according to member benefits.

    Orthodontic benefits are only applicable to members under the age of 18 years Retreatment of orthodontic cases is not covered

    Orthognathic and associated hospitalization is not covered
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    PERIODONTICS

    Restricted to root planning only. Service providers must complete Hosmed periodontal screening forms. Members will then be logged on the periodontal care programme.

    Periodontal surgery is an exclusion . Pre-authorization must be given for periodontal treatment. Unauthorized treatment will not be covered by the scheme.
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    HOSPITALIZATION

    Preauthorization is required for dental treatment under general anaesthetic, failing which all costs related to the procedure will not be paid.

    Panoramic X-Ray must be provided to ensure that Hosmed dental protocols are adhered to.

    1. Removal of impacted teeth will attract benefits only when the teeth are impacted by bone. Impaction by soft tissue alone will not attract the benefit
    2. Hospitalization for children under the age of 7 years who require multiple fillings/extractions will be assessed for authorization .Multiple hospitalization admission will not be covered
    3. Dental Hospital Exclusions:
      1. Apisectomies on premolar , anterior and 3rd Molars
      2. Dentectomies
      3. Frenectomies
      4. Conservative dental treatment eg fillings on adults, fissure sealant ,fluoride treatment, polishing
    4. Single impactation extraction or soft tissue impactaions.

    Preauthorization for hospitalization must be submitted to :
    Hosmed Hospital Authorization, Tel: 011 290 6384

    The following information must be provided:

    1. Members details
    2. Panoramic X-ray
    3. Service providers details, practice no
    4. Hospital details
    5. Codes and tooth no
    6. Estimated time in theatre
    7. 72 hours notice prior to procedure
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    DENTAL THERAPIST

    Value Plan - Limited to R500.00 per member per year and R1000.00 per family per year.

    Plus Plan - Limited to R750.00 per member per year and R1 500.00 per family per year.
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    DENTAL BENEFIT TABLE

    SERVICES BENEFITS
    Consultation & Fillings 2 annual check ups per beneficiary.
    Benefit for fillings is available where such fillings are clinically indicated and will be granted once per tooth in a 3 year period.
    More than 4 fillings per member per year must log on to the dental care programme failing which benefits will not be paid by the scheme.
    Prophylaxis

    CONSERVATIVE DENTISTRY    		 2 annual scale & polish per member.
    Fluoride benefits only on members under 18 years.
    No benefits for oral hygiene instructions.
    Fissure sealant only performed on molars under the age of 18.
    6 P.A. X-Rays annually per member.
    4 bite-wing X-Rays annually per member.
    Crowns

    SPECIALIZED DENTISTRY    		 2 crowns per family per year.
    Pre-authorization is required.
    X-Rays to be supplied.
    Benefit for crowns are granted once per tooth per 5 years.
    Orthodontics Pre-authorization is required. Authorization applied to functional treatment 20% co-payment applies
    Periodontal Treatment Benefits awarded to members on periodontal care plan. It is limited to root plannings and non-surgical therapy.
    Implants No benefits.
    Hospitalization Pre-authorization required
    Plastic Dentures 1 set of dentures every 4 years.
    Relines every 2 years.
    Metal framework benefit available every 5 years.
    Full metal framework is not covered.
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