12-Dental Booklet 3246050003.0724 8.14.25.pdf

Your Dental Care Benefit Booklet A Guide to Your Group Dental Care Coverage

DEN-CB-COC-LG-2023-NM Customer Service: (877) 723-5697

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

DEN-CB-COC-LG-2023-NM

CERTIFICATE OF COVERAGE

Blue Cross and Blue Shield of New Mexico (herein called “BCBSNM” or “Carrier”)

Hereby certifies that it has issued a Group Dental Benefits Contract (herein called the “Plan”). Subject to the provisions of the Plan, each Employee (Subscriber) to whom a Blue Cross and Blue Shield of New Mexico Identification Card is issued, together with eligible Dependents for whom application is initially made and accepted, shall have coverage under the Plan, beginning on the Effective Date, if the Employer makes timely payment of total premium due to the Carrier. Issuance of this Benefit Booklet by BCBSNM does not waive the eligibility and Effective Date provisions stated in the Plan.

Janice Torrez President of Blue Cross and Blue Shield of New Mexico

The covered person shall have the right to return the plan within 30 days of its delivery, and to have the premium and any required membership fees refunded, if after examination of the plan the covered person is not satisfied for any reason, provided no claim has been paid.

The Dental Schedule of Coverage enclosed with this Benefit Booklet indicates benefit percentages, Deductibles, maximums, and other benefit and payment issues that apply to the Plan.

NOTICE TO CONSUMER: This is a limited benefits health plan. The benefits provided are supplemental to, and not a substitute for, major medical coverage even in combination with other limited health plans. To apply for an individual or small-group major medical plan, please visit the website of the New Mexico Health Insurance Exchange at www.bewellnm.com or call

1-833-862-3935 (TTY: 711).

http://www.bewellnm.com/

TABLE OF CONTENTS

Page No.

Certificate of Coverage Important Notice

Dental Schedule of Coverage ..........................................................................................................Enclosure

Introduction

Who Gets Benefits

How the Plan Works

Claim Filing and Appeals Procedures

Eligible Dental Expenses, Payment Obligations, and Benefits

Covered Dental Services

Services not Covered

Definitions

General Provisions

Amendments

Notices

INTRODUCTION

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This Plan is offered by your Employer as one of the benefits of your employment. The benefits provided are intended to assist you with many of your dental care expenses for Dentally Necessary services and supplies.

Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity, sexual orientation or religion. There are provisions throughout this Benefit Booklet that affects your dental care coverage. It is important that you read the Benefit Booklet carefully so you will be aware of the benefits and requirements of this Plan.

The defined terms in this Benefit Booklet are capitalized and shown in the appropriate provision in the Benefit Booklet or in the DEFINITIONS section of the Benefit Booklet. Whenever these terms are used, the meaning is consistent with the definition given. Terms in italics may be section headings describing provisions or they may be defined terms.

The terms “you” and “your” as used in this Benefit Booklet refer to the Employee. Use of the masculine pronoun “his,” “he,” or “him” will be considered to include the feminine unless the context clearly indicates otherwise.

Benefits available under the Plan are explained in the COVERED DENTAL SERVICES section. The benefits available to you are indicated on the Dental Schedule of Coverage in this Benefit Booklet.

You are covered only for those benefit categories of services selected by your Employer and shown on your Dental Schedule of Coverage.

The benefit percentage to be applied to each category of service is shown on your Dental Schedule of Coverage.

Important Contact Information

Resource Contact Information Accessible Hours Dental Customer Service

Helpline 1-877-723-5697 Monday – Friday

8:00 a.m. – 6:00 p.m.

(hours are subject to change)

Website www.bcbsnm.com 24 hours a day 7 days a week

Dental Customer Service Helpline

Dental Customer Service Representatives can:

Give you information about Contracting Dentists;

Distribute claim forms;

Answer your questions on claims;

Assist you in identifying a Contracting Dentist (but will not recommend specific Dentists);

Provide information on the features of the Plan.

BCBSNM Website

Visit the BCBSNM website at www.bcbsnm.com for information about BCBSNM, access to forms referenced in this Benefit Booklet, and much more.

http://www.bcbsnm.com/ http://www.bcbsnm.com/

WHO GETS BENEFITS

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Eligibility

The Eligibility Date is the date a person becomes eligible to be covered under the Plan. A person becomes eligible to be covered when he becomes an Eligible Employee or a Dependent under the Plan. The Eligibility Date is:

The date the Employee, including any Dependents to be covered, completes the Waiting Period, if any, for coverage;

For a new Dependent of an Employee already having coverage under the Plan, the date the Employee acquired the Dependent (date of marriage, birth, Court Order, placement of a foster child, adoption, or placement for adoption).

Any person eligible under this Contract and covered by the Employer’s previous dental care Plan on the date prior to the Contract Date, including any person who has continued group coverage under applicable federal or state law is eligible on the Contract Date. Otherwise, you are eligible for coverage under the Plan when you satisfy the definition of an Eligible Employee.

Dependent Eligibility If you apply for coverage, you may include your Dependents. Eligible Dependents are:

1. Your spouse or your Domestic Partner.

2. A child under the limiting age shown in the definition of Dependent;

3. A child of any age who is medically certified as Disabled and dependent on you;

4. Any other child included as an eligible Dependent under the Contract. A detailed description of

Dependent is in the DEFINITIONS section of this Benefit Booklet.

An Employee must be covered first in order to cover his eligible Dependents. No Dependent shall be covered hereunder prior to the Employee’s Effective Date.

Applying For Coverage

You may apply for coverage for yourself and your eligible Dependents by submitting an Enrollment Application/Change form to your Employer or BCBSNM.

No eligibility rules or variations in premium will be imposed based on your health status, dental condition, claims experience, receipt of health care, dental history, genetic information, evidence of insurability, disability, or any other health status related factor. Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or benefits of this Plan that are based on clinically indicated, reasonable dental management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination.

Effective Dates of Coverage

The Effective Date is the date the coverage for a Participant actually begins.

It is important that your application for coverage under the Plan is received timely by the Carrier. If you apply for coverage and pay any required premium for yourself and your eligible Dependents and if you:

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1. Are eligible on the Contract Date and the application is received by the Carrier prior to or within 31 days following such date, your coverage will become effective on the Contract Date;

2. Enroll for coverage for yourself or your Dependents during an Open Enrollment Period, coverage shall become effective on the Contract Anniversary Date, provided your application is received timely by the Carrier.

In no event will your Dependent’s coverage become effective prior to your Effective Date.

Late Applications If you apply for coverage for yourself or for yourself and any Dependents and your application is not received within 31 days from your Eligibility Date, you will not be eligible to apply for coverage until the next Open Enrollment Period unless qualified for a Special Enrollment Period.

Special Enrollment Periods Special enrollment periods have been designated during which you may apply for or request a change in coverage for yourself and/or your eligible Dependents. You must apply for coverage within 31 days from the date of a triggering event in order to qualify for the changes described in this Special Enrollment Period subsection, including the following:

1. Birth, Adoption, or Placement for Adoption, Placement of a Foster Child or Court-Ordered Dependent Coverage The Effective Date of coverage will be the date of birth, adoption, or placement for adoption or date of placement of a foster child. The Effective Date of coverage for Court-Ordered Dependent coverage will be determined by BCBSNM in accordance with the provisions of the Court Order.

2. Marriage The Effective Date of coverage will be no later than the first day of the month following your marriage date or establishment of a domestic partnership.

BCBSNM must receive notification from you on an Enrollment Application/Change Form during the 31- day period after the event. If you wait until after this 31-day period, the coverage will become effective on the Contract Anniversary Date following your Employer’s next Open Enrollment Period.

Enrollment Application/Change Form

Use this form to...

Notify the Plan and BCBSNM of a change to your name;

Add Dependents (other than a newborn child where notification only is required);

Drop Dependents;

Cancel all or a portion of your coverage;

Notify BCBSNM of all changes in address for yourself and your Dependents.

You may obtain this form from your Employer, by calling the BCBSNM Dental Customer Service Helpline telephone number shown in this Benefit Booklet or on your Identification Card, or by accessing the BCBSNM website. If a Dependent’s address and zip code are different from yours, be sure to indicate this information on the form. After you have completed the form, return it to your Employer.

Changes in Your Family

You should promptly notify the Carrier, as appropriate, in the event of a birth or follow the instructions below when events, such as the following take place:

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If you are adding a Dependent due to marriage or establishment of a domestic partnership, or placement of a foster child, adoption, or placement for adoption, or your Employer receives a Court Order to provide health or dental coverage for a Participant’s child or your spouse, you must submit an Enrollment Application/Change Form and the coverage of the Dependent will become effective as described in this WHO GETS BENEFITS section.

When you divorce or terminate a domestic partnership, your child reaches the Dependent child age limit or a Participant in your family dies, coverage under the Plan terminates in accordance with the Termination of Coverage provisions.

Notify your Employer promptly if any of these events occur. Benefits for expenses incurred after termination are not available. If your Dependent’s coverage is terminated, premium refunds will not be made for any period before the date of notification. If benefits are paid prior to notification to BCBSNM, refunds will be requested.

Please refer to the Continuation of Group Coverage - Federal subsection in this Benefit Booklet for additional information.

HOW THE PLAN WORKS

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Allowable Amount

The Allowable Amount is the maximum amount of benefits BCBSNM will pay for Eligible Dental Expenses you incur under the Plan. The portion of the charges by your Dentist that exceeds the Allowable Amount of BCBSNM will be your responsibility to pay to your Dentist, except when you have used a Contracting Dentist. You will also be responsible for charges for services, supplies, and procedures limited or not covered under the Plan and any applicable Deductibles and Coinsurance Amounts.

Review the definition of Allowable Amount in the DEFINITIONS section of this Benefit Booklet to understand the guidelines used by BCBSNM.

Course of Treatment

Your Dentist may decide on a planned series of dental procedures which a dental exam shows you need. In cases where there is more than one professionally acceptable covered procedure or Course of Treatment, benefits will be covered for the least costly covered procedure or Course of Treatment, as determined by the Plan. If the Participant requests or accepts the more costly service, the person is responsible for expenses that exceed the amount covered for the least costly service.

Current Dental Terminology (CDT)

The most recent edition of the manual published by the American Dental Association (ADA) entitled “Current Dental Terminology and Procedure Codes (CDT)” is used when classifying dental services.

The Allowable Amount for an Eligible Dental Expense will be based on the most inclusive procedure codes.

Freedom of Choice Each time you need dental care, you can choose to:

See a Contracting Dentist See a Non-Contracting Dentist Your out-of-pocket cost will generally be the least amount because Contracting Dentists have contracted to accept a lower Allowable Amount as payment in full for Eligible Dental Expenses;

You are not required to file claim forms;

You are not balance billed for costs exceeding the BCBSNM Allowable Amount for Contracting Dentists.

Your out-of-pocket cost may be greater because Non-Contracting Dentists have not entered into a contract with BCBSNM to accept any Allowable Amount determination as payment in full for Eligible Dental Expenses;

You are required to file claim forms;

You may be balanced billed by Non-Contracting Dentists for costs exceeding the BCBSNM Allowable Amount.

In each event as described above, you will be responsible for the following:

any applicable Deductibles;

Coinsurance Amounts;

Services that are limited or not covered under the Plan.

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If your Dentist is not a Contracting Dentist, you may be responsible for filing your claim, as described in the CLAIM FILING AND APPEALS PROCEDURES portion of this Benefit Booklet. You may also be responsible for payment in full at the time services are rendered.

To find a Contracting Dentist, you may look up a dental Provider in the Dental Directory, log on to the Blue Cross and Blue Shield of New Mexico website at www.bcbsnm.com and search for a Dentist using Provider Finder, or call the Dental Customer Service Helpline number located in this Benefit Booklet or on your Identification Card.

How Benefits are Calculated

Your benefits are based on a percentage of the Dentist’s Allowable Amount. To determine your benefits, subtract the Deductible (if applicable and not previously satisfied) from your Eligible Dental Expenses, then, multiply the difference by the Coinsurance Amount percentage applicable to the benefit category of services shown on your Dental Schedule of Coverage. The resulting total is the amount of benefits available.

The remaining unpaid amounts, including any excess portion above the Allowable Amount, except when you have used a Contracting Dentist, any Deductible, and your Coinsurance Amount will be your responsibility to pay to your Dentist.

When using a Non-Contracting Dentist, your out–of-pocket cost may be greater because Non-Contracting Dentists have not entered into a contract with BCBSNM to accept any Allowable Amount determination as payment in full for Eligible Dental Expenses. You may be balanced billed by Non-Contracting Dentists for costs exceeding the BCBSNM Allowable Amount.

Identification Card

The Identification Card tells Providers that you are entitled to benefits under your Employer’s dental care plan with BCBSNM. The card offers a convenient way of providing important information specific to your coverage including, the following:

Your Subscriber identification number. This unique identification number is preceded by a three character alpha prefix that identifies Blue Cross and Blue Shield of New Mexico as your Carrier.

Your group number. This is the number assigned to identify your Employer’s dental care Plan with

BCBSNM.

Important telephone numbers.

Always remember to carry your Identification Card with you and present it to your Dentist when receiving dental care services or supplies. Do not let anyone who is not named in your coverage use your Identification Card to receive benefits.

Please remember that any time a change in your family takes place it may be necessary for a new Identification Card to be issued to you (refer to the WHO GETS BENEFITS section for instructions when changes are made). Upon receipt of the change in information, the Carrier will provide a new Identification Card.

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Predetermination of Benefits

If a Course of Treatment for non-emergency services can reasonably be expected to involve Eligible Dental Expenses in excess of $300, a description of the procedures to be performed and an estimate of the Dentist’s charge may be filed with and predetermined by BCBSNM prior to the commencement of treatment.

BCBSNM may request copies of existing radiographic images, photographs, models, and any other records used by the Dentist in developing the Course of Treatment. BCBSNM will review the reports and materials, taking into consideration alternative Courses of Treatment. BCBSNM will notify you and the Dentist of the benefits to be provided under the Plan. Predetermination of the procedures to be performed and an estimate of the Dentist’s charge is not required, but when provided it gives you and your Dentist the opportunity to know the extent of the benefits available. Benefit payments may be reduced based on any claims paid after a predetermination estimate is provided.

CLAIM FILING AND APPEALS PROCEDURES

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This section explains how to file claims to obtain benefits, how claims are processed, and what to do if you disagree with the action taken on your claim.

A Subscriber’s coverage (including coverage for his or her Dependents, if any) shall be terminated retroactive to the Effective Date if the Group or Subscriber commits fraud or material misrepresentation in applying for or obtaining coverage under the Group Contract. A member’s coverage shall terminate immediately if he or she files a fraudulent claim.

In order to obtain your dental benefits under this benefit program, it is necessary for a claim to be filed with BCBSNM. If you use a Contracting Dentist, he or she will file your claims for you, and payment will be sent directly to the Dentist. You will receive an Explanation of Benefits (EOB) form BCBSNM showing the benefits provided.

If you use a Non-Contracting Dentist, it is your responsibility to file the claim. Payment for covered services will be sent to you.

You will receive an EOB whether we send payment to you or the Dentist. Benefit payment is subject to any applicable Deductible and/or Coinsurance Amount requirements.

BCBSNM will pay all claims within 30 days of receipt of all information required to process a claim. If the claim is denied in whole or in part, you will receive a notice from BCBSNM with:

1. The reason for denial;

2. A reference to the benefit program provisions on which the denial is based;

3. A description of additional information which may be necessary to perfect the appeal; and

4. An explanation of how you may have the claim reviewed by BCBSNM if you do not agree with the denial.

If You Have Other Valid Coverage

If this dental benefit program is secondary to another plan you need to file your claim with the other carrier first (see Coordination of Benefits).

If a Dentist normally files claims to BCBSNM and the other carrier does not pay the Dentist directly, the Dentist will need, from you, a copy of the other carrier’s explanation of benefits to include with the claim sent to BCBSNM.

If a Non-Contracting Dentist does not file claims for you, attach a copy of the Non-Contracting Dentist’s explanation of benefits to the claim that you send to BCBSNM.

How to File Claims

Most Providers will bill BCBSNM on the Participant’s behalf using the proper claim forms. When you must file your own claim, however, request the appropriate claim form from the Dental Administrative Offices, 1- 877-723-5697 or obtain an Attending Dentist’s Statement from BCBSNM before going to your Dentist. The Attending Dentist’s Statement is also used for requesting predetermination estimates. It is your responsibility to ensure that the necessary claim information has been provided. When BCBSNM has been notified of a claim the claim form shall be furnished to the covered person within fifteen days after notice of claim. The covered person shall be deemed to have complied with the requirement to provide proof of loss if the notice of claim contains written proof describing the claim, including the character and extent of the loss of which the claim is made. Adequate proof of loss must be in the possession of BCBSNM at the time funds are disbursed in payment of claims.

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You must complete and sign the Subscriber/Participant Information of the Attending Dentist’s Statement. As soon as treatment has ended, ask your Dentist to complete and sign the Attending Dentist’s Statement, and file it with:

Blue Cross and Blue Shield of New Mexico P. O. Box 23090

Belleville, IL 62223-0090

If a Provider will not complete the Attending Dentist’s Statement or does not bill BCBSNM directly, it is the Participant’s responsibility to attach to the claim form, and submit to BCBSNM, itemized bills that include all necessary information (balance due statements, cash register receipts, and canceled checks are not acceptable).

Timely Filing Limits

All claims must be filed within 180 days after the date of service. Any claims filed after this time limit may be denied, unless BCBSNM is satisfied that there is a valid reason why the Participant could not submit his/her claim within this time limit. In no case will claims be paid that are filed later than 365 days after the date of service.

If a claim must be returned to the Participant for additional information, the claim must be resubmitted to BCBSNM within 45 days of the date the claim was returned to the Participant.

If a Participant’s coverage under this dental benefit program ends, claims for covered services must be filed within 180 days after the date of the coverage termination. Failure to file a claim within the 180 days will result in loss of benefits otherwise provided by this dental benefit program if, as a result of such failure by the Participant, BCBSNM is unable to perform adequate claims review.

Claim Forms and Itemized Bills

All information on the claim form and itemized statements must be readable. If information is missing on the claim form or it is not readable, then BCBSNM will return it to the Participant or to the Provider. Handwritten entries added to a typed or computerized claim form that change or add procedure codes are considered fraudulent and will require the Participant’s and the Provider’s signatures acknowledging approval of such information.

The information on the itemized bills is used to determine benefits, so it must support information reported on the submitted claim form. All claims must include:

Subscriber’s benefit program ID number Subscriber’s name and address Participant’s name Participant’s age and relationship to the Subscriber Other dental coverage in effect Date of service Type of treatment Itemization of charges Accident or surgery date (when applicable) Name and address of Provider Provider’s tax ID number or social security number Participant’s signature Provider’s signature

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If an itemized bill from the Provider is not attached to a claim form, the Dentist must complete the “Dentist Information Section” and the “Examination and Treatment Record” of the Attending Dentist’s Statement and must sign the claim form.

Benefits cannot be determined if documentation is missing or radiographs submitted are not of sufficient diagnostic quality to determine benefits.

Separate Claim Forms Required A separate claim form is required for each Provider for which you are requesting reimbursement. A separate claim form is also required for each Participant when charges for more than one family member are being submitted.

Where to Send Claim Forms

Send claims to:

Blue Cross and Blue Shield of New Mexico Dental Administrative Office

P. O. Box 23090 Belleville, IL 62223-0090

Claim and Predetermination Estimate Appeal Procedures

If your claim or predetermination estimate has been denied in whole or in part, you may have your claim reviewed. BCBSNM will review its decision in accordance with the following procedure. Within 180 days after you receive notice of a denial or partial denial, write to BCBSNM. BCBSNM will need to know the reason why you do not agree with the denial or partial denial.

Send your request to:

Blue Cross and Blue Shield of New Mexico Dental Administrative Office

P. O. Box 23090 Belleville, IL 62223-0090

You may also designate a representative to act for you in the review procedure. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. While BCBSNM will honor telephone requests for information, such inquiries will not constitute a request for review.

You and your authorized representative may ask to see relevant documents and may submit written issues, comments and additional dental information within 180 days after you receive notice of a denial or partial denial. BCBSNM will give you a written decision within 60 days after receiving your request for review.

If you have any questions about the claims procedures or the review procedure, write or call BCBSNM.

BCBSNM offices are open from 7:45 A.M. to 3:45 P.M., Mountain Time, Monday through Friday.

Blue Cross and Blue Shield of New Mexico 300 East Randolph Chicago, IL 60601

1-866-431-1604

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Other Resources to Help You

For questions about your rights or for assistance; and filing a complaint you can also contact the Consumer Assistance Bureau at the Office of Superintendent of Insurance. Send your request to:

Office of Superintendent of Insurance Consumers Assistance Bureau

P.O. Box 1689 Santa Fe, NM 87504-1689

Telephone: 1-855-4ASK-OSI (1-855-427-5674)

Actions Against BCBSNM

No lawsuit or action in law or equity may be brought by you or on your behalf prior to the expiration of 60 days after Proof of Loss has been filed in accordance with the requirement of the Plan and no such action will be brought at all unless brought within three years from the expiration of the time within which Proof of Loss is required by the Plan.

ELIGIBLE DENTAL EXPENSES, PAYMENT OBLIGATIONS, AND

BENEFITS

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Eligible Dental Expenses

The Plan provides coverage for services and supplies that are considered Dentally Necessary. The benefit percentage to be applied to each category of service is shown on the Dental Schedule of Coverage.

For benefits available for Eligible Dental Expenses, please refer to the Dental Schedule of Coverage in this Benefit Booklet. Your benefits are calculated on a Calendar or Plan Year basis unless otherwise stated. At the end of a Calendar or Plan Year, a new benefit period starts for each Participant.

Deductibles

The benefits of the Plan will be available after satisfaction of the applicable Deductibles as shown on your Dental Schedule of Coverage. The Deductibles are explained as follows:

Calendar or Plan Year Deductible: The individual Deductible amount shown under “Deductible” on your Dental Schedule of Coverage must be satisfied by each Participant under your coverage each Calendar or Plan Year. This Deductible, unless otherwise indicated, will be applied to all categories of services, before benefits are available under the Plan.

The following are exceptions to the Deductibles described above.

Your Dental Schedule of Coverage indicates “Three-Month Deductible Carryover applies”. This means that any Eligible Dental Expenses incurred during the last three months of a Calendar or Plan Year and applied toward satisfaction of the “Deductible” for that Plan Year may be applied toward satisfaction of that Deductible for the following Plan Year.

If you have several covered Dependents, all charges used to apply toward a “per individual” amount will be applied toward the “per family” amount shown on your Dental Schedule of Coverage. When that family Deductible amount is reached, no further individual Deductibles will have to be satisfied for the remainder of that Calendar or Plan Year. No Participant will contribute more than the individual Deductible amount to the family Deductible amount.

Maximum Dental Benefits

Annual Maximum Benefit The total amount of benefits available to any one Participant for all combined categories of services for a Calendar or Plan Year shall not exceed the “Annual Maximum Benefit” amount shown on your Dental Schedule of Coverage.

This Annual Maximum Benefit amount includes:

1. All payments made by BCBSNM under the benefit provisions of the Plan; and

2. Any benefits provided to a Participant under a dental care plan held by the Employer with BCBSNM immediately prior to the Participant’s Effective Date of coverage under this Plan.

Maximum Lifetime Benefits The total amount of benefits available to any one Participant under the Plan shall not exceed the “Maximum Lifetime Benefits” amount as shown on your Dental Schedule of Coverage.

ELIGIBLE DENTAL EXPENSES, PAYMENT OBLIGATIONS, AND

BENEFITS

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This Maximum Lifetime Benefits amount includes all payments made by BCBSNM under the Orthodontic Services provision of the Plan as indicated on your Dental Schedule of Coverage.

Changes in Benefits

Benefits for Eligible Dental Expenses incurred during a Course of Treatment that begins before the change will be those benefits in effect on the day the Course of Treatment was started.

COVERED DENTAL SERVICES

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The Plan will provide benefits for the following Eligible Dental Expenses, subject to the limitations and exclusions described in this Benefit Booklet, only if the category of service is shown on your Dental Schedule of Coverage. The benefit percentage applicable to each category of service is also shown on your Dental Schedule of Coverage.

You are covered only for those categories of services shown on the Dental Schedule of Coverage issued with this Benefit Booklet.

Diagnostic Evaluations Diagnostic evaluations aid the Dentist in determining the nature or cause of a dental disease and include:

Periodic oral evaluations for established patients.

Problem focused exam, whether limited, detailed or extensive.

Comprehensive oral evaluations for new or established patients.

Comprehensive periodontal evaluations for new or established patients.

Clinical oral examinations when performed as a part of an emergency service to relieve pain and suffering.

Oral evaluations of children under three years of age, including counseling with primary caregiver.

Benefits for periodic, extensive, and detailed oral evaluations are limited to a combined maximum of two exam(s) every Calendar Year. Comprehensive oral evaluations are limited to one every 36 months when performed by the same Dentist.

Benefits will not be provided for comprehensive periodontal evaluations or problem-focused evaluations when Eligible Dental Expenses are rendered on the same date as any other oral evaluation by the same Dentist.

Tests and oral pathology procedures, or for re-evaluations are not covered.

Preventive Services Preventive services are performed to prevent dental disease. Eligible Dental Expenses include:

Prophylaxis – Professional cleaning and polishing of the teeth. Benefits are limited to two cleaning(s) every Calendar Year.

Scaling in presence of generalized moderate or severe gingival inflammation. Benefits are limited to one per Calendar Year.

Topical application of fluoride – Benefits for topical application of fluoride are available for Participants under age 16 or older if Medically Necessary and are limited to two application(s) every Calendar Year.

Combination of prophylaxes, scaling in presence of generalized moderate or severe gingival inflammation and periodontal maintenance treatments are limited to a combination of two every Calendar Year.

Diagnostic Radiographs Diagnostic radiographic images are taken to diagnose a dental disease and include their interpretations. Eligible Dental Expenses include:

Full-mouth (intraoral complete series) and panoramic films – Benefits are limited to a combined maximum of one every 60 months.

Bitewing films – Benefits are limited to four horizontal images or eight vertical radiographic images

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once every Calendar or Plan Year unless, greater frequency is deemed medically necessary.

Bitewing films are not separately eligible when taken on the same date as full-mouth films.

Periapical films for diagnosis – Benefits are limited to six every Calendar or Plan Year 12 months.

Miscellaneous Preventive Services

Miscellaneous preventive services are other services performed to prevent dental disease and include:

Sealants – Benefits for sealants are limited to one per permanent (first and second) molar every five years as medically necessary. Coverage may be excluded when an occlusal restoration has been completed on the tooth.

Space Maintainers – Benefits for space maintainers are limited to a lifetime maximum of one appliance per arch for Participants up to age 14.

Charges for nutritional, tobacco or oral hygiene counseling are not covered.

Basic Restorative Services

Basic restorative services are restorations necessary to repair dental decay, including tooth preparation, all adhesives, bases, liners and polishing. Eligible Dental Expenses include:

Amalgam restorations – Benefits shall cover necessary fillings for cavities.

Resin-based composite restorations – Benefits shall cover necessary fillings for cavities.

Non-Surgical Extractions

Non-surgical extractions are non-surgical removal of tooth and tooth structures and include:

Removal of retained coronal remnants – deciduous tooth.

Removal of erupted tooth or exposed root.

Non-Surgical Periodontal Services

Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes:

Periodontal scaling and root planing – Benefits are limited to once per quadrant every 36 months.

Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime.

Periodontal maintenance procedures – Benefits are limited to two every Calendar Year following active periodontal treatment.

Enhanced Benefits Participants diagnosed and receiving active medical care for the following medical conditions as determined by the Plan such as – pregnancy, diabetes, and cardiovascular disease – may receive one of the following enhanced dental benefits after standard benefits are completed:

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One additional cleaning; or

Periodontal scaling and root planing (up to 2 quadrants); or

Periodontal maintenance.

Enhanced benefits apply to the annual benefit maximum.

Chemical treatments or localized delivery of chemotherapeutic agents are not covered.

Adjunctive Services

Adjunctive general services include:

Palliative treatment (emergency) of dental pain, when treatment is not performed in conjunction with a definitive treatment or service.

Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Medically Necessary by the Plan for Participants with documented medical or dental conditions. A person’s apprehension does not constitute a Medical Necessity.

Charges for local anesthesia, nitrous oxide analgesia, therapeutic, parenteral drugs, or other drugs or medicaments and/or their application are not covered.

Endodontic Services

Endodontics is the treatment of dental disease of the tooth pulp and includes:

Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure.

Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care.

Apexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection.

Pulpal debridement is considered part of endodontic therapy when performed by the same Dentist and not associated with a definitive emergency visit.

Oral Surgery Services

Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes:

Surgical tooth extractions.

Alveoloplasty and vestibuloplasty.

Excision of benign odontogenic tumor/cysts.

Excision of bone tissue.

Incision and drainage of an intraoral abscess. Intraoral soft tissue incision and drainage is covered only when provided as the definitive treatment for an abscess. Routine follow-up care is considered part of the procedure.

Other Medically Necessary surgical and repair procedures not specifically excluded in this Contract.

Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for

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dentures or other prosthesis); treatment of fractures of facial bones; external incision and drainage of cellulitis;

incision of accessory sinuses, salivary glands or ducts; reduction of dislocation, or excision of the temporomandibular joints are not covered.

Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological) or for bony impactions covered by another benefit plan are not covered.

Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof or floor of the mouth are not covered.

Surgical Periodontal Services

Surgical periodontal service is the surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes:

Gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits are limited to no more than one surgical periodontal procedure (periodontal surgery, osseous surgery, gingivectomy or gingivoplasty) per quadrant every 36 months.

Clinical crown lengthening once per lifetime per tooth.

Osseous surgery, including flap entry and closure – Benefits are limited to one per quadrant every 36 months. In addition, osseous surgery performed in conjunction with crown lengthening on the same date of service and in the same area of the mouth, will receive the benefit of crown lengthening in the absence of periodontal disease.

Osseous grafts – Benefits are limited to one per quadrant every 36 months.

Soft tissue grafts/allografts (including donor site) – Benefits are limited to one per quadrant every 36 months.

Distal or proximal wedge procedure, limited to one per quadrant every 36 months, not in conjunction with osseous surgery.

Surgical periodontal services performed in conjunction with the placement of crowns, inlays, onlays, crown buildups, posts and cores, or basic restorations are considered part of the restoration.

Anatomical crown exposure not covered.

Major Restorative Services

Restorative services restore tooth structures lost as a result of dental decay or fracture and include:

Single crown restorations.

Inlay/onlay restorations.

Labial veneer restorations not performed for cosmetic reasons.

Benefits for major restorations are limited to one per tooth every 8 years whether placement was provided under this Contract or under any prior dental coverage, even if the original crown was stainless steel. Crowns placed over implants will be covered.

Prosthodontic Services

Prosthodontics involves procedures necessary for providing artificial replacements for missing natural teeth and includes:

Complete and removable partial dentures – Benefits will be provided for the initial installation of

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removable complete, immediate or partial dentures, including any adjustments, relines or rebases during the six-month period following installation. Benefits for replacements are limited to once in any 8 year period, whether placement was provided under this Contract or under any prior dental coverage.

Denture reline/rebase procedures – Benefits will be limited to once in any procedure every 36 month period.

Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the prosthetic delivery.

Fixed bridgework – Benefits will be provided for the initial installation of an eligible bridgework, including inlays/onlays and crowns. Benefits will be limited to once per tooth in any 8 year period whether placement was under this Contract or under any prior dental coverage.

Prosthetics placed over implants will be covered.

Miscellaneous Restorative and Prosthodontic Services

Other restorative and prosthodontics services include:

Prefabricated crowns – Benefits for stainless steel and resin-based crowns are limited to one per tooth every 8 years. These crowns are not intended to be used as temporary crowns.

Recementation of inlays/onlays, crowns, bridges, and post and core – Benefits will be limited to two recementations per Calendar or Plan Year. Recementation provided within six months of an initial placement by the same Dentist is considered part of the initial placement.

Post and core, pin retention, and crown and bridge repair services.

Pulp cap – direct and indirect.

Adjustments – Benefits will be limited to two time(s) per appliance per Calendar Year.

Repairs of inlays, onlays, veneers, crowns, fixed or removable dentures, including replacement or addition of a missing or broken tooth or clasp (unless additions are completed on the same date as replacement partials/dentures) - Benefits are limited to a lifetime maximum of once per tooth or clasp.

Orthodontic Services Orthodontic procedures and treatment include examination, records, tooth guidance repositioning (straightening) and retention of the teeth for Participants covered for orthodontics as shown on your Dental Schedule of Coverage. Covered services include:

Limited, interceptive and comprehensive orthodontic treatment, which all accumulate to the Participant’s lifetime maximum.

Special Provisions Regarding Orthodontic Services:

Orthodontic services are paid over the Course of Treatment, up to the maximum orthodontic benefit, as shown on your Dental Schedule of Coverage. Benefits cease when the Participant is no longer covered, whether or not the entire benefit has been paid.

Orthodontic treatment is started on the date the bands or appliances are inserted.

Payment for diagnostic services performed in conjunction with orthodontics is applied to the orthodontic benefit and subject to the maximum benefit, as shown on your Dental Schedule of Coverage for orthodontic services.

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If orthodontic treatment is terminated for any reason before completion, benefits will cease on the date of termination.

If the Participant’s coverage is terminated prior to the completion of the orthodontic treatment plan, the Participant is responsible for the remaining balance of treatment costs.

Recementation of an orthodontic appliance by the same Dentist who placed the appliance and/or who is responsible for the ongoing care of the Participant is not covered.

Benefits are not available for replacement or repair of an orthodontic appliance.

For services in progress on the Effective Date, benefits will be reduced based on the benefits paid prior to this coverage beginning.

Implant Services

Depending on the dental Plan chosen, benefits may be available for covered services incurred for an artificial device specifically designed to be placed surgically in the mouth as a means of replacing missing teeth. See your Dental Schedule of Coverage for more information.

Benefits Not Covered

No benefits will be provided under this Contract for:

1. Services or supplies not specifically listed as an Eligible Dental Expense, or when they are related to a non-covered service.

2. Amounts which are in excess of the Allowable Amount, as determined by the Plan.

3. Dental services for treatment of congenital or developmental malformation, or services performed for cosmetic purposes, including:

bleaching teeth; and grafts to improve aesthetics.

4. Dental services which are performed due to an Accidental Injury. Injury caused by chewing or biting an object or substance placed in your mouth is not considered an Accidental Injury.

5. Services and supplies for any illness or injury suffered after the Participant’s Effective Date:

as a result of war or any act of war, declared or undeclared; or while on active or reserve duty in the armed forces of any country or international authority.

6. Services or supplies that are not Dentally Necessary or do not meet accepted standards of dental practice.

7. Services or supplies which are Experimental/Investigational in nature or not fully approved by a Council of the American Dental Association.

8. Hospital and ancillary charges.

9. Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage.

10. Services or supplies for which “discounts” or waiver of Deductible or Coinsurance Amounts are offered.

11. Services or supplies received from someone other than a Dentist, except for those services received from a licensed dental hygienist under the supervision and guidance of a Dentist, where applicable.

12. Services or supplies received for behavior management or consultation purposes.

13. Any services or supplies provided in connection with an occupational sickness or an injury sustained in

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the scope of and in the course of any employment whether or not benefits are, or could upon proper claim be, provided under the Workers’ Compensation law.

14. Any services or supplies for which benefits are, or could upon proper claim be, provided under any laws enacted by the Legislature of any state, or by the Congress of the United States, or any laws, regulations or established procedures of any county or municipality, except any program which is a state plan for medical/dental assistance (Medicaid); provided, however, that this exclusion shall not be applicable to any coverage held by the Participant for dental expenses which is written as a part of or in conjunction with any automobile casualty insurance policy.

15. Charges for local, state or territorial taxes on dental services or procedures.

16. Charges for the administration of infection control procedures as required by OSHA, local, state or federal mandates.

17. Charges for duplicate, temporary or provisional prosthetic device or other duplicate, temporary or provisional appliances.

18. Charges for telephone consultations, email or other electronic consultations, missed appointments, completion of a claim form or forwarding requested records or radiographic images.

19. Charges for prescription or non-prescription mouthwashes, rinses, topical solutions, preparations or medicament carriers.

20. Charges for personalized complete or partial dentures and overdentures, related services and supplies, or other specialized techniques.

21. Charges for athletic mouth guards, isolation of tooth with rubber dam, metal copings, mobilization of erupted/malpositioned tooth, precision attachments for partials and/or dentures and stress breakers.

22. Charges for a partial or full denture or fixed bridge which includes replacement of a tooth which was missing prior to your Effective Date under this Contract; except this exclusion will not apply to:

Any Participant who has been continuously covered for 24 months under a group dental care contract with BCBSNM or a combination of coverage of BCBSNM and the previous group dental care contract by the Employer, which included prosthetic benefits.

A partial or full denture or fixed bridge which includes replacement of a missing tooth which was extracted after your Effective Date.

23. Replacement of an extracted or missing third molar and/or congenitally missing teeth.

24. Any services, treatments or supplies included as Eligible Dental Expenses under other hospital, medical and/or surgical coverage.

25. Case presentations or detailed and extensive treatment planning when billed for separately.

26. Charges for occlusion analysis or occlusal adjustments.

27. Guided tissue regeneration, or for biologic materials to aid in tissue regeneration.

28. Charges for replacement of stolen, lost, or defective dentures, crowns or other appliances.

29. Splinting of teeth including double retainers for removable partial dentures and fixed bridgework.

30. Any procedure, service, or appliance for the purpose of altering or maintenance of vertical dimension of occlusion.

31. Appliances or restoration of teeth due to lost vertical dimension of occlusion, erosion, attrition, abrasion, or abfraction. Benefits are not provided for the appliances or restorations to restore occlusion or incisal edges due to bruxism or harmful habits.

32. Any procedure, service, or appliance provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall be considered cosmetic.

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33. Precision or semiprecision attachments.

SERVICES NOT COVERED

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Dental coverage is limited to services provided by a Dentist, a dental auxiliary, (as defined in the DEFINITIONS section) licensed to perform services covered under this dental Contract.

Important Information About Your Dental Benefits Dental Procedures Which Are Not Medically Necessary

Please note that in order to provide you with dental care benefits at a reasonable cost, this Contract…