Pacific Care Dental Plan, California Plan Limitations and Exclusion

Wednesday, Apr. 27th 2011 6:07 AM

The orthodontic benefit covers: consultation, all necessary appliances, banding, and monthly office visits for 24 months. Specific co-payment levels have also been set for start-up and retention services.  Orthodontic treatment must be provided by a Panel Orthodontist. A referral must be submitted by the assigned general dentist and approved by the Plan. Rates and coverage’s subject to change without notification.

LIMITATIONS AND EXCLUSION:

ARBITRATION: The Plan uses binding arbitration to resolve any and all disputes between the Plan and group or member, including, but not limited to, allegations against Plan of medical malpractice (that is an to whether any dental services rendered under the Plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) and other disputes relating to the delivery of services under the Plan.

Plan, group and member each understand and expressly agree that by entering into the Plan services group subscriber agreement or enrolling in Plan and agreeing to be bound by the Plan subscriber agreement. Plan, group and member are each voluntarily giving up their constitutional right to have all such disputes decided in a court of law before a jury and instead are accepting the is of binding arbitration. Group and member further contracting provider including but not limited to claims against a Plan contracting provider for medical malpractice are not governed by the Plan subscriber agreement.

However Plan, group and member each expressly agree that the existence of any disputes between group or member and a Plan contracting provider, including but not limited to claims by groups or member against a Plan contracting provider for medical malpractice shall in no way affect the obligation to submit to binding arbitration all disputes between group or member and Plan.

LIMITATIONS: Dentures or partials once every five years and then only when dentures cannot be made serviceable; cleanings once every six months; relines not more than twice per year; full mouth x-rays once every two years; all family members must be assigned to the same dental office; orthodontic treatment must be provided by a member of the Plan Orthodontic Panel.

EXCLUSIONS: Oral surgery requiring the setting of fractures or dislocations; treatment of malignancies, cysts or neoplasms; dispensing of drugs; teeth extracted for orthodontic purposes; cosmetic dentistry; treatment of temporomandibular joint syndrome (tmj); treatment by a specialist.


DISCLOSURE: An application is a request for coverage which if approved by the Plan would then become the enrollment form and would be used to issue an identification card and a Disclosure Form. Upon acceptance of the application by the Plan, your benefits will become effective on the first of the next month. Detailed limitations and exclusions, coverage benefits, co-payments, as well as other services offered, are given in full in the Disclosure Form provided when coverage becomes effective. The Insurance Company always reserves the right to make the final determination with respect to all aspects of this Dental Program.

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Posted on Wednesday, Apr. 27th 2011 6:07 AM | by Share of Cost | in Share of Cost | No Comments »

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