sizwe medical fund dental benefit table...
TRANSCRIPT
1
PRIMARY CARE DENTAL BENEFIT TABLE 2017
AFFORDABLE CARE DENTAL BENEFIT TABLE 2017
FULL BENEFIT DENTAL BENEFIT TABLE 2017
Dental benefits are paid at the Sizwe Dental tariff (SDT). Hospitalisation and certain specialised dentistry
procedures, and treatments must be pre-authorised*. Procedures and treatment not authorised will not be eligible
for funding. If authorisation is approved after the treatment has been done, a 20% penalty will apply. This is
applicable to hospitalisation (the hospital account) and for the following specialised out-of-hospital dentistry
treatments: crowns and bridges, implants, periodontics and IV conscious sedation in the dental rooms. Failure
to pre-authorise orthodontic treatment will result in a payment ONLY from date of authorisation for the remaining
months of treatment, provided that the treatment is approved as per the managed care protocols. Penalties do
not apply to emergency/PMB** hospital admission.
Dental benefits are subject to managed care protocols and managed care interventions which may include the
requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental
benefits. In the event of a dispute, the rules of the scheme will prevail.
Primary Care: Voluntary admissions in hospitals that are not participating in the scheme’s Hospital DSP Network
will be subjected to a co-payment of 20% (the hospital account).
** PMB = Prescribed Minimum Benefits
NOTE: In 2017 Family Limits are applicable to both Conservative and Specialised Dentistry. The Orthodontic
Benefit is NOT subject to the Specialised Dentistry Limit.
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
CO
NS
ER
VA
TIV
E D
EN
TIS
TR
Y
Consultations
2 annual check-ups per
beneficiary (once in 6
months).
Benefit is subject to
managed care protocols.
Covered at the SDT.
2 annual check-ups per
beneficiary (once in 6
months).
Benefit is subject to
managed care protocols.
Covered at the SDT.
2 annual check-ups per
beneficiary (once in 6
months).
Benefit is subject to
managed care protocols.
Covered at the SDT.
Sizwe Medical Fund Dental Benefit Table
2017
2
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
X-rays: Intra-oral Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is subject to
managed care protocols.
Covered at the SDT.
X-rays: Extra-oral
1 per beneficiary in a 3 year
period.
Benefit is subject to
managed care protocols.
Covered at the SDT.
1 per beneficiary in a 3
year period.
Benefit is subject to
managed care protocols.
Additional benefit may be
considered where
specialised dental
treatment is required.
Covered at the SDT.
1 per beneficiary in a 3
year period.
Benefit is subject to
managed care protocols.
Additional benefit may be
considered where
specialised dental
treatment is required.
Covered at the SDT.
Oral Hygiene
2 annual scale and polish
treatments per beneficiary
(once in 6 months).
Benefit is subject to
managed care protocols.
Benefit for fissure sealants
is limited to beneficiaries
younger than 16 years of
age.
Benefit for fluoride is
limited to beneficiaries
from age 5 and younger
than 13 years of age.
Covered at the SDT.
Scheme exclusions:
Oral hygiene instruction
Oral hygiene evaluation
Professionally applied
2 annual scale and polish
treatments per beneficiary
(once in 6 months).
Benefit is subject to
managed care protocols.
Benefit for fissure
sealants is limited to
beneficiaries younger than
16 years of age.
Benefit for fluoride is
limited to beneficiaries
from age 5 and younger
than 13 years of age.
Covered at the SDT.
Scheme exclusions:
Oral hygiene instruction
Oral hygiene evaluation
Professionally applied
2 annual scale and polish
treatments per
beneficiary (once in 6
months).
Benefit is subject to
managed care protocols.
Benefit for fissure
sealants is limited to
beneficiaries younger
than 16 years of age.
Benefit for fluoride is
limited to beneficiaries
from age 5 and younger
than 13 years of age.
Covered at the SDT.
Scheme exclusions:
Oral hygiene instruction
Oral hygiene evaluation
3
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
fluoride for beneficiaries 13 years and older
Dental bleaching
fluoride for beneficiaries 13 years and older
Dental bleaching
Professionally applied fluoride for beneficiaries 13 years and older
Dental bleaching
Fillings
Benefit for fillings are
granted once per tooth in
365 days.
Benefit for re-treatment of a
tooth is subject to managed
care protocols.
Covered at the SDT.
A treatment plan and x-rays
may be required for multiple
fillings.
Scheme exclusions:
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis
Resin bonding for restorations that are charged as a separate procedure to the restoration
The polishing of restorations
Gold foil restorations
Ozone therapy
Benefit for fillings are
granted once per tooth in
365 days.
Benefit for re-treatment of
a tooth is subject to
managed care protocols.
Covered at the SDT.
A treatment plan and x-
rays may be required for
multiple fillings.
Scheme exclusions:
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis
Resin bonding for restorations that are charged as a separate procedure to the restoration
The polishing of restorations
Gold foil restorations
Ozone therapy
Benefit for fillings are
granted once per tooth in
365 days.
Benefit for re-treatment of
a tooth is subject to
managed care protocols.
Covered at the SDT.
A treatment plan and x-
rays may be required for
multiple fillings.
Scheme exclusions:
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis
Resin bonding for restorations that are charged as a separate procedure to the restoration
The polishing of restorations
Gold foil restorations
Ozone therapy
Root Canal
Therapy and
Extractions
Benefit is subject to
managed care protocols.
Covered at the SDT.
Scheme exclusions:
Benefit is subject to
managed care protocols.
Covered at the SDT.
Scheme exclusions:
Benefit is subject to
managed care protocols.
Covered at the SDT.
Scheme exclusions:
4
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
Root canal therapy on primary (milk) teeth
Root canal therapy on wisdom teeth (3rd molars)
Direct and indirect pulp capping procedures
Root canal therapy on primary (milk) teeth
Root canal therapy on wisdom teeth (3rd molars)
Direct and indirect pulp capping procedures
Root canal therapy on primary (milk) teeth
Root canal therapy on wisdom teeth (3rd molars)
Direct and indirect pulp capping procedures
Plastic Dentures
and
associated
Laboratory costs
1 set of plastic dentures, full
or partial (an upper and a
lower) per beneficiary in a 4
year period.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is not available for
the clinical fee of denture
repairs, denture tooth
replacements and the
addition of a soft base to
new dentures; the
laboratory fee will be
covered.
Benefit is not available for
the laboratory fee of
mouthguards; the clinical
fee will be covered.
Scheme exclusions:
Diagnostic dentures and associated laboratory costs
Snoring appliances and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semiprecious metal and
1 set of plastic dentures
full or partial (an upper
and a lower) per
beneficiary in a 4 year
period.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is not available for
the clinical fee of denture
repairs, denture tooth
replacements and the
addition of a soft base to
new dentures; the
laboratory fee will be
covered.
Benefit is not available for
the laboratory fee of
mouthguards; the clinical
fee will be covered.
Scheme exclusions:
Diagnostic dentures and associated laboratory costs
Snoring appliances and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semiprecious metal and
1 set of plastic dentures,
full or partial (an upper
and a lower) per
beneficiary in a 4 year
period.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is not available
for the clinical fee of
denture repairs, denture
tooth replacements and
the addition of a soft
base to new dentures;
the laboratory fee will be
covered.
Benefit is not available
for the laboratory fee of
mouthguards; the clinical
fee will be covered.
Scheme exclusions:
Diagnostic dentures and associated laboratory costs
Snoring appliances and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semiprecious metal and
5
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
platinum foil
Laboratory delivery fees
Provisional dentures and associated laboratory costs
platinum foil
Laboratory delivery fees
Provisional dentures and associated laboratory costs
platinum foil
Laboratory delivery fees
Provisional dentures and associated laboratory costs
SP
EC
IAL
ISE
D D
EN
TIS
TR
Y
Partial Metal
Frame Dentures
and associated
Laboratory costs
No benefit
2 partial frames (an upper
and a lower) per
beneficiary in a 5 year
period, limited to 1 family
member per annum.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Scheme exclusions:
The metal base to full dentures and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semiprecious metal and platinum foil
Laboratory delivery fees
2 partial frames (an
upper and a lower)
per beneficiary in a 5
year period, limited to 2
family members per
annum.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Scheme exclusions:
The metal base to full dentures and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semiprecious metal and platinum foil
Laboratory delivery fees
Crown & Bridge*
and
associated
Laboratory costs
A bridge
comprises 2 or
more crown units.
Each crown is
payable from the
No benefit
Pre-authorisation is
required.
1 crown per family per
year.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Pre-authorisation is
required.
3 crowns per family per
year.
Benefit is subject to
managed care protocols.
Covered at the SDT.
6
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
available Crown
and Bridge
benefit.
Benefits for crowns are
granted once per tooth in
a 5 year period.
A treatment plan and x-
rays may be requested.
Scheme exclusions:
Crown or crown retainers on wisdom teeth (3rd molars)
Pontics on 2nd molars
Crown and bridge procedures for cosmetic reasons and associated laboratory costs
Occlusal rehabilitations and associated laboratory costs
Provisional crowns and associated laboratory costs
Porcelain veneers and inlays and associated laboratory costs
Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs
The cost of gold, precious metal, semiprecious metal and platinum foil
Laboratory delivery fees
Benefits for crowns are
granted once per tooth in
a 5 year period.
A treatment plan and x-
rays may be requested.
Scheme exclusions:
Crown or crown retainers on wisdom teeth (3rd molars)
Pontics on 2nd molars
Crown and bridge procedures for cosmetic reasons and associated laboratory costs
Occlusal rehabilitations and associated laboratory costs
Provisional crowns and associated laboratory costs
Porcelain veneers and inlays and associated laboratory costs
Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs
The cost of gold, precious metal, semiprecious metal and platinum foil
Laboratory delivery fees
Implants* and
associated
Laboratory costs
No benefit
No benefit
Pre-authorisation is
required.
2 implants per beneficiary
in a 5 year period.
7
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
Benefit is subject to
managed care protocols.
Covered at the SDT.
Cost of implant
component is limited to
R3 500 per implant.
Scheme exclusions:
Implants on wisdom teeth (3rd molars)
Dolder bars and associated abutments on implants including the associated laboratory costs
Laboratory delivery fees
Orthodontics*
and associated
Laboratory costs
Note: NOT
subjected to the
Specialised
Dentistry Limit
No benefit
Pre-authorisation is
required.
Benefit is subject to
managed care protocols
and will only be funded
from date of authorisation.
On pre-authorisation
cases will be clinically
assessed by using an
orthodontic needs
analysis. Benefit
allocation is subject to the
outcome of the needs
analysis and funding can
be granted up to 65% of
SDT.
Benefit for Orthodontic
Pre-authorisation is
required
Benefit is subject to
managed care protocols
and will only be funded
from date of
authorisation.
On pre-authorisation
cases will be clinically
assessed by using an
orthodontic needs
analysis. Benefit
allocation is subject to
the outcome of the needs
analysis and funding can
be granted up to 100% of
SDT.
Benefit for Orthodontic
treatment will be granted
8
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
treatment will be granted
where function is
impaired.
Benefit will not be granted
where Orthodontic
treatment is required for
cosmetic reasons. The
associated Laboratory
costs will also not be
covered.
Only one family member
may commence
Orthodontic treatment in a
calendar year.
Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age.
Scheme exclusions:
Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory costs
Orthodontic re-treatment and any related laboratory costs
Invisible retainer material
Laboratory delivery fees
where function is
impaired.
Benefit will not be
granted where
Orthodontic treatment is
required for cosmetic
reasons. The associated
Laboratory costs will also
not be covered.
Only one family member
may commence
Orthodontic treatment in
a calendar year.
Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age.
Scheme exclusions:
Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory costs
Orthodontic re-treatment and any related laboratory costs
Invisible retainer material
Laboratory delivery fees
Periodontics*
Covered at the SDT.
Benefit is limited to
conservative, non-surgical
therapy only and will only
be applied to members who
are registered on the
Covered at the SDT.
Benefit is limited to
conservative, non-surgical
therapy only and will only
be applied to members
who are registered on the
Covered at the SDT.
Benefit is limited to
conservative, non-
surgical therapy only and
will only be applied to
members who are
9
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
Periodontal Programme.
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Surgical Periodontics – no
benefit.
Scheme exclusions:
Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth
Perio chip placement
Periodontal Programme.
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Surgical Periodontics – no
benefit.
Scheme exclusions:
Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth
Perio chip placement
registered on the
Periodontal Programme.
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Surgical Periodontics –
subject to managed care
protocols.
Scheme exclusions:
Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth
Perio chip placement
Maxillo-Facial
Surgery
and Oral
Pathology
Surgery in the dental chair:
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit for Temporo-
mandibular Joint (TMJ)
therapy is limited to non-
surgical intervention/
treatments.
The claims for oral
pathology procedures
(cysts and biopsies, the
surgical treatment of
tumours of the jaw and soft
tissue tumours) will only be
Surgery in the dental
chair:
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit for Temporo-
mandibular Joint (TMJ)
therapy is limited to non-
surgical intervention/
treatments.
The claims for oral
pathology procedures
(cysts and biopsies, the
surgical treatment of
tumours of the jaw and
soft tissue tumours) will
Surgery in the dental
chair:
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit for Temporo-
mandibular Joint (TMJ)
therapy is limited to non-
surgical intervention/
treatments.
The claims for oral
pathology procedures
(cysts and biopsies, the
surgical treatment of
tumours of the jaw and
soft tissue tumours) will
10
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
covered if supported by a
laboratory report that
confirms diagnosis.
Scheme exclusions:
Orthognathic (jaw correction) surgery
Bone augmentations
Bone and tissue regeneration procedures
The cost of bone regeneration material
The auto-transplantation of teeth
Sinus lift procedures
The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.
Surgery in hospital:
See Hospitalisation* below
only be covered if
supported by a laboratory
report that confirms
diagnosis.
Scheme exclusions:
Orthognathic (jaw correction) surgery
Bone augmentations
Bone and tissue regeneration procedures
The cost of bone regeneration material
The auto-transplantation of teeth
Sinus lift procedures
The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.
Surgery in hospital:
See Hospitalisation*
below
only be covered if
supported by a laboratory
report that confirms
diagnosis.
Scheme exclusions:
Orthognathic (jaw correction) surgery
Bone augmentations
Bone and tissue regeneration procedures
The cost of bone regeneration material
The auto-transplantation of teeth
Sinus lift procedures
The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.
Surgery in hospital:
See Hospitalisation*
below
11
HO
SP
ITA
LIS
AT
ION
AN
D A
NA
ES
TH
ET
ICS
Hospitalisation
(general
anaesthetic)*
Pre-authorisation is
required
A co-payment of R1 500
per hospital admission
applies.
Admission protocols apply.
General anaesthetic
benefits are available for
children under the age of 5
years for extensive dental
treatment.
General anaesthetic
benefits are available for
the removal of impacted
teeth. Benefit is subject to
managed care protocols.
The Hospital and
anaesthetist claims for the
following procedures will
not be covered when
performed under general
anaesthesia.
The payment of the dental
procedure will be
dependent on available
benefits and payable at
SDT:
Apicectomies
Dentectomies
Frenectomies
Implantology and associated surgical procedures
Pre-authorisation is
required.
A co-payment of R1 500
per hospital admission
applies.
Admission protocols
apply.
General anaesthetic
benefits are available for
children under the age of
5 years for extensive
dental treatment.
General anaesthetic
benefits are available for
the removal of impacted
teeth. Benefit is subject to
managed care protocols.
The Hospital and
anaesthetist claims for the
following procedures will
not be covered when
performed under general
anaesthesia.
The payment of the dental
procedure will be
dependent on available
benefits and payable at
SDT:
Apicectomies
Dentectomies
Frenectomies
Implantology and associated surgical procedures
Pre-authorisation is
required.
A co-payment of R1 500
per hospital admission
applies.
Admission protocols
apply.
General anaesthetic
benefits are available for
children under the age of
5 years for extensive
dental treatment.
General anaesthetic
benefits are available for
the removal of impacted
teeth. Benefit is subject
to managed care
protocols.
The Hospital and
anaesthetist claims for
the following procedures
will not be covered when
performed under general
anaesthesia.
The payment of the
dental procedure will be
dependent on available
benefits and payable at
SDT:
Apicectomies
Dentectomies
Frenectomies
Implantology and associated surgical procedures
Conservative dental Conservative dental Conservative dental
12
PRIMARY CARE
Conservative Dentistry Limit
of R2 800 per family
AFFORDABLE CARE
Conservative Dentistry
Limit of R3 200 per family
Specialised Dentistry
Limit of R3 200 per family
FULL BENEFIT
Conservative Dentistry
Limit of R3 600 per family
Specialised Dentistry
Limit of R3 600 per family
treatment (fillings, extractions and root canal therapy) for adults
Professional oral hygiene procedures
Surgical tooth exposure for orthodontic reasons
Scheme exclusions:
Where the only reason for admission to hospital is dental fear and anxiety
Multiple hospital admissions
Where the only reason for the admission request is for a sterile facility
The cost of dental materials for procedures performed under general anaesthesia
treatment (fillings, extractions and root canal therapy) for adults
Professional oral hygiene procedures
Surgical tooth exposure for orthodontic reasons
Scheme exclusions:
Where the only reason for admission to hospital is dental fear and anxiety
Multiple hospital admissions
Where the only reason for the admission request is for a sterile facility
The cost of dental materials for procedures performed under general anaesthesia
treatment (fillings, extractions and root canal therapy) for adults
Professional oral hygiene procedures
Surgical tooth exposure for orthodontic reasons
Scheme exclusions:
Where the only reason for admission to hospital is dental fear and anxiety
Multiple hospital admissions
Where the only reason for the admission request is for a sterile facility
The cost of dental materials for procedures performed under general anaesthesia
Laughing gas in
dental rooms
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is subject to
managed care protocols.
Covered at the SDT.
IV conscious
sedation in
rooms*
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is limited to
extensive dental treatment.
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is limited to
extensive dental
treatment.
Pre-authorisation is
required.
Benefit is subject to
managed care protocols.
Covered at the SDT.
Benefit is limited to
extensive dental
treatment.
13
Additional scheme exclusions:
Electrognathographic recordings, pantographic recordings and other such electronic analyses
Nutritional and tobacco counseling
Caries susceptibility and microbiological tests
Fissure sealants on patients 16 years and older
Pulp tests
Cost of Mineral Trioxide
Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
Appointment not kept
Special report
Dental testimony including Dento-legal fees
Treatment plan completed (currently code 8120)
Enamel microabrasion
Behaviour management
Intramuscular or subcutaneous injection
Procedures that are defined as unusual circumstances and procedures that are defined as unlisted
procedures
Primary specific exclusions:
Specialised dentistry: crowns & bridges, implants, orthodontics and surgical periodontics
Metal base to full dentures
Partial metal frame dentures
14
Sizwe Savings Care Dental Benefit Table 2017
Dental benefits are paid at the Sizwe dental tariff (SDT). Dental benefits are payable form available funds in the member's savings account for out of hospital services.
Dental treatment in hospital and under IV conscious sedation in the dental rooms must be pre-authorised*.
If no pre-authorisation is obtained:
In-hospital: If authorisation is approved after the treatment has been done, a 20% penalty will apply on the hospital account. Penalties do not apply to emergency/PMB** hospital admission.
Out of hospital: If authorisation for IV conscious sedation is approved after the treatment has been done, a 20% penalty will apply.
Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental benefits. In the event of a dispute, the rules of the scheme will prevail.
** PMB = Prescribed Minimum Benefits
SIZWE SAVINGS CARE OPTION
CO
NS
ER
VA
TIV
E D
EN
TIS
TR
Y
Consultations Available funds in the savings account.
Once in 6 months.
Benefit is subject to managed care protocols.
Covered at the SDT.
X-rays: Intra-oral Available funds in the savings account.
Benefit is subject to managed care protocols.
Covered at the SDT.
X-rays: Extra-oral Available funds in the savings account.
1 per beneficiary in a 3 year period.
Benefit is subject to managed care protocols. Additional benefit may be considered where specialised dental treatment is required.
Covered at the SDT.
Oral Hygiene Available funds in the savings account.
Once in 6 months.
Benefit is subject to managed care protocols.
Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age.
Benefit for fluoride is limited to beneficiaries from age 5 and younger than 13
15
SIZWE SAVINGS CARE OPTION
years of age.
Covered at the SDT.
Scheme exclusions:
Oral hygiene instruction
Oral hygiene evaluation
Professionally applied fluoride for beneficiaries 13 years and older
Dental bleaching
Fillings Available funds in the savings account.
Benefit for fillings are granted once per tooth in 365 days.
Benefit for re-treatment of a tooth is subject to managed care protocols.
Covered at the SDT.
A treatment plan and x-rays may be required for multiple fillings.
Scheme exclusions:
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis
Resin bonding for restorations that are charged as a separate procedure to the restoration
The polishing of restorations
Gold foil restorations
Ozone therapy
Root Canal Therapy and Extractions
Available funds in the savings account.
Benefit is subject to managed care protocols.
Covered at the SDT.
Scheme exclusions:
Root canal therapy on primary (milk) teeth
Root canal therapy on wisdom teeth (3rd molars)
Direct and indirect pulp capping procedures
Plastic Dentures and associated Laboratory costs
Available funds in the savings account
Benefit is subject to managed care protocols.
Covered at the SDT.
Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered.
Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered.
16
SIZWE SAVINGS CARE OPTION
Scheme exclusions:
Diagnostic dentures and associated laboratory costs
Snoring appliances and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semi-precious metal and platinum foil
Laboratory delivery fees
Provisional dentures and associated laboratory costs
SP
EC
IAL
ISE
D D
EN
TIS
TR
Y Partial Metal
Frame Dentures and associated Laboratory costs
Available funds in the savings account.
Benefit is subject to managed care protocols.
Covered at the SDT.
Scheme exclusions:
The metal base to full dentures and associated laboratory costs
High impact acrylic
The cost of gold, precious metal, semi-precious metal and platinum foil
Laboratory delivery fees
Crown & Bridge and associated Laboratory costs
A bridge comprises 2 or more crown units. Each crown is payable from the available Crown and Bridge benefit.
Available funds in the savings account
Benefit is subject to managed care protocols.
Covered at the SDT.
Benefits for crowns are granted once per tooth in a 5 year period.
A treatment plan and x-rays may be requested.
Scheme exclusions:
Crown or crown retainers on wisdom teeth (3rd molars)
Pontics on 2nd molars
Crown and bridge procedures for cosmetic reasons and associated laboratory costs
Occlusal rehabilitations and associated laboratory costs
Provisional crowns and associated laboratory costs
Porcelain veneers and inlays and associated laboratory costs
Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs.
The cost of gold, precious metal, semi-precious metal and platinum foil
Laboratory delivery fees
Implants Available funds in the savings account.
Benefit is subject to managed care protocols.
Covered at the SDT.
Scheme exclusions:
Implants on wisdom teeth (3rd molars)
17
SIZWE SAVINGS CARE OPTION
Dolder bars and associated abutments on implants including the associated laboratory costs
Laboratory delivery fees
Orthodontics
and associated Laboratory costs
Available funds in the savings account.
Benefit is subject to managed care protocols.
Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger than 18 years of age.
Scheme exclusions:
Orthognathic (jaw correction) and other orthodontic related surgery and any related Hospital cost including associated Laboratory costs
Orthodontic re-treatment and any related Laboratory costs
Invisible retainer material
Laboratory delivery fees
Periodontics Available funds in the savings account
Benefit is subject to managed care protocols.
Covered at the SDT.
Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme.
Scheme exclusions:
Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemi section of a tooth
Perio chip placement
18
SIZWE SAVINGS CARE OPTION
Maxillo-Facial Surgery
and Oral Pathology in Rooms
( excluding removal of impacted teeth under IV conscious sedation)
Available funds In the savings account
Benefit is subject to managed care protocols.
Covered at the SDT.
Benefit for Temporo-mandibular Joint (TMJ) therapy is limited to non-surgical intervention/treatments.
The claims for oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report that confirms diagnosis.
Scheme exclusions:
Orthognathic (jaw correction) surgery
Bone augmentations
Bone and tissue regeneration procedures
The cost of bone regeneration material
The auto-transplantation of teeth
Sinus lift procedures
The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.
Surgery in hospital:
See Hospitalisation* below
19
SIZWE SAVINGS CARE OPTION H
OS
PIT
AL
ISA
TIO
N A
ND
AN
AE
ST
HE
TIC
S
Hospitalisation (general anaesthetic)*
Pre-authorisation is required.
A co-payment of R1 500 per hospital admission applies.
Admission protocols apply.
General anaesthetic benefits are available for children under the age of 5 years
for extensive dental treatment.
General anaesthetic benefits are available for the removal of impacted teeth.
Benefit is subject to managed care protocols.
The Hospital and anaesthetist claims for the following procedures will not be
covered when performed under general anaesthesia. The payment of the dental
procedure will be dependent on available benefits and payable at SDT:
Apicectomies
Dentectomies
Frenectomies
Implantology and associated surgical procedures
Conservative dental treatment (fillings, extractions and root canal therapy) for adults
Professional oral hygiene procedures
Surgical tooth exposure for orthodontic reasons Scheme exclusions:
Where the only reason for admission to hospital is dental fear and anxiety
Multiple hospital admissions
Where the only reason for the admission request is for a sterile facility.
The cost of dental materials for procedures performed under general anaesthesia
Laughing gas in dental rooms
Available funds in the savings account.
Benefit is subject to managed care protocols.
Covered at the SDT.
IV conscious sedation in rooms*
Pre-authorisation is required.
Removal of impacted teeth only.
Benefit is subject to managed care protocols.
Covered at the SDT.
20
Additional scheme exclusions:
Electrognathographic recordings, pantographic recordings and other such electronic analyses
Nutritional and tobacco counseling
Caries susceptibility and microbiological tests
Fissure sealants on patients 16 years and older
Pulp tests
Cost of Mineral Trioxide
Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
Appointment not kept
Special report
Dental testimony including Dento-legal fees
Treatment plan completed (currently code 8120)
Enamel microabrasion
Behaviour management
Intramuscular or subcutaneous injection
Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures
21
Sizwe Hospital Care Dental Benefit Table 2017
Dental benefits are paid at the Sizwe dental tariff (SDT).
Dental treatment in hospital and under IV conscious sedation in the dental rooms must be pre-authorised*.
If no pre-authorisation is obtained:
In-hospital: If authorisation is approved after the treatment has been done, a 20% penalty will apply on the hospital account. Penalties do not apply to emergency/PMB** hospital admission.
Out of hospital: If authorisation for IV conscious sedation is approved after the treatment has been done, a 20% penalty will apply.
Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental benefits. In the event of a dispute, the rules of the scheme will prevail.
** PMB = Prescribed Minimum Benefits
SIZWE HOSPITAL CARE OPTION
CO
NS
ER
VA
TIV
E D
EN
TIS
TR
Y
Consultations No Benefit
X-rays: Intra-oral No Benefit
X-rays: Extra-oral No Benefit
Oral Hygiene No Benefit
Fillings No Benefit
Root Canal Therapy and Extractions
No Benefit
Plastic Dentures and associated Laboratory costs
No Benefit
22
SIZWE HOSPITAL CARE OPTION S
PE
CIA
LIS
ED
DE
NT
IST
RY
Partial Metal Frame Dentures and associated Laboratory costs
No Benefit
Crown & Bridge and associated Laboratory costs
No Benefit
Implants No Benefit
Orthodontics
and associated Laboratory costs
No Benefit
Periodontics No Benefit
Maxillo-Facial Surgery
and Oral Pathology in Rooms
( excluding removal of impacted teeth under IV conscious sedation)
No Benefit
23
SIZWE HOSPITAL CARE OPTION H
OS
PIT
AL
ISA
TIO
N A
ND
AN
AE
ST
HE
TIC
S
Hospitalisation (general anaesthetic)*
Pre-authorisation is required.
A co-payment of R1 500 per hospital admission applies.
Admission protocols apply.
General anaesthetic benefits are available for children under the age of 5 years
for extensive dental treatment.
General anaesthetic benefits are available for the removal of impacted teeth.
Benefit is subject to managed care protocols.
Scheme exclusions:
Where the only reason for admission to hospital is dental fear and anxiety
Multiple hospital admissions
Where the only reason for the admission request is for a sterile facility.
The cost of dental materials for procedures performed under general anaesthesia
Laughing gas in dental rooms
No Benefit
IV conscious sedation in rooms*
Pre-authorisation is required.
Limited to the In-Hospital dental benefits.
Benefit is subject to managed care protocols.
Covered at the SDT.
Additional scheme exclusions:
Electrognathographic recordings, pantographic recordings and other such electronic analyses
Nutritional and tobacco counseling
Caries susceptibility and microbiological tests
Fissure sealants on patients 16 years and older
Pulp tests
Cost of Mineral Trioxide
Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
Appointment not kept
Special report
Dental testimony including Dento-legal fees
Treatment plan completed (currently code 8120)
Enamel microabrasion
Behaviour management
Intramuscular or subcutaneous injection
Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures