RFP_26-041-DJ_Appendix G_Option V_DPPO Premier Plan - draft.xlsx
XLSX spreadsheet 19 KB Posted
- Attached to
- Multiple Option Dental Program
- Solicitation number
- RFP 680 26-041/DJ 4
- Issued by
- Palm Beach County, Florida
About this file
This document is a Benefit Comparison Worksheet for Option V - DPPO Premier Plan, part of RFP No. 26-041/DJ for Florida's Multiple Option Dental Program. The worksheet details comprehensive dental benefit coverage across diagnostic, preventive, basic, major restorative, and orthodontic services. Coverage includes diagnostic services such as radiographs, cultures, and evaluations; preventive services including prophylaxis, fluoride treatments, and sealants for children; basic services covering amalgam and composite restorations; major restorative services encompassing endodontics, periodontics, oral surgery, implants, fixed and removable prosthetics; and orthodontic services limited to members under age 19. The plan establishes specific frequency limitations for most procedures, such as limited bitewing radiographs to one series per 12 months, prophylaxis to two cleanings per 12 months, and major restorative procedures to one occurrence per 60 consecutive months.
The DPPO Premier Plan utilizes a tiered coinsurance structure with network providers offering higher coverage levels than out-of-network providers. Diagnostic and preventive services are covered at 100 percent in-network and 90 percent out-of-network, while basic services are covered at 80 percent in-network and 70 percent out-of-network. Major restorative services, endodontics, periodontics, oral surgery, adjunctive services, implants, fixed and removable prosthetics, and orthodontic appliance therapy are covered at 50 percent in-network and 40 percent out-of-network, except for certain orthodontic services covered at 50 percent both in-network and out-of-network. Specific exclusions and limitations apply throughout the plan, including restrictions on laboratory-based procedures used for provisional splinting, limitations on implant coverage to one replacement per 60 months when the previous prosthesis is not serviceable, and coverage restrictions for certain anesthesia services based on medical necessity criteria.
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Appendix G - Opt V DPPO Premier
| APPENDIX G | ||||||||
| BENEFIT COMPARISON WORKSHEET | ||||||||
| RFP NO. 26-041/DJ | ||||||||
| OPTION V - DPPO PREMIER PLAN | ||||||||
| PROPOSER'S RESPONSE | ||||||||
| BENEFIT DESCRIPTION & LIMITATION | NETWORK COINSURANCE | OUT-OF-NETWORK COINSURANCE | COVERED - Y/N | NETWORK COINSURANCE | OUT-OF-NETWORK COINSURANCE | LIMITATIONS | EXCLUSIONS | |
| DIAGNOSTIC SERVICES | ||||||||
| Bacteriologic Cultures | 100% | 90% | ||||||
| Viral Cultures | 100% | 90% | ||||||
| Intraoral Bitewing Radiographs | ||||||||
| Limited to 1 series of films per consecutive 12 months. | 100% | 90% | ||||||
| Panorex Radiographs or Intraoral - Complete Series (including bitewings) |
Limited to 1 time per consecutive 36 months. Vertical bitewings cannot be billed in conjunction with
| a complete series. | 100% | 90% | |
| Oral/Facial Photographic Images | |||
| Limited to 1 time per consecutive 36 months. | 100% | 90% | |
| Diagnostic Casts | |||
| Limited to 1 time per consecutive 24 months. | 100% | 90% | |
| Extraoral Radiographs | |||
| Limited to 2 films per consecutive 12 months. | 100% | 90% | |
| Intraoral Periapical Radiographs | 100% | 90% | |
| Pulp Vitality Tests | |||
| Limited to 1 charge per visit, regardless of how many teeth are tested. | 100% | 90% | |
| Intraoral Occlusal Film | 100% | 90% | |
| Periodic Oral Evaluation | |||
| Limited to 2 times per consecutive 12 months. | 100% | 90% | |
| Comprehensive Oral Evaluation | |||
| Limited to 1 time per Dentist per consecutive 36 months. Not Covered if done in conjunction with other exams. | 100% | 90% | |
| Limited or Detailed Oral Evaluation | |||
| Only 1 exam is Covered per date of service. | 100% | 90% | |
| Comprehensive Periodontal Evaluation - new or established patient | |||
| Limited to 1 time per Dentist per consecutive 36 months. Not Covered if done in conjunction with other exams. | 100% | 90% | |
| Adjunctive Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures. | |||
| Limited to 1 time per consecutive 12 months. | 100% | 90% | |
| PREVENTIVE SERVICES | |||
| Space Maintainers | |||
| Limited to Covered Persons under the age of 16 years, 1 time per consecutive 60 months. Benefit includes all adjustments within 6 months of installation. | 100% | 90% | |
| Dental Prophylaxis | |||
| Limited to two (2) prophylaxis in any 12 consecutive months, to a maximum of two (2) total prophylaxis and/or periodontal maintenance cleanings in any 12 consecutive months. | 100% | 90% | |
| Fluoride Treatments - child | |||
| Limited to Covered Persons under the age of 16 years, and limited to 1 time per consecutive 12 months. | 100% | 90% | |
| Sealants | |||
| Limited to Covered Persons under the age of 16 years and to 1 time per first or second unrestored permanent molar every consecutive 36 months. | 100% | 90% | |
| BASIC SERVICES (including, but not limited to, ORAL SURGERY, ADJUNCTIVE SERVICES) | |||
| Re-Cement Space Maintainers | |||
| Limited to 1 time per appliance per consecutive 6 months after initial insertion. | 100% | 90% | |
| Amalgam Restorations | |||
| Multiple restorations on one surface will be treated as a single filling. | 80% | 70% | |
| Composite Resin Restorations | |||
| Multiple restorations on one surface will be treated as a single filling. | 80% | 70% | |
| Re-Cement Inlays/Onlays, Crowns, Bridges and Post and Core | |||
| Limited to those performed more than 12 months after the initial insertion. | 80% | 70% | |
| MAJOR RESTORATIVE SERVICES (including, but not limited to, FIXED PROSTHETICS, REMOVABLE PROSTHETICS, ENDODONTICS, PERIODONTICS, IMPLANTS) | |||
| ENDODONTICS | |||
| Apexification | |||
| Limited to 1 time per root per lifetime. | 50% | 40% | |
| Apicoectomy and Retrograde Filling | |||
| Limited to 1 time per root per lifetime. | 50% | 40% | |
| Hemisection | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Root Canal Therapy - Anterior | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Root Canal Therapy - Posterior | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Retreatment of Previous Root Canal Therapy | |||
| Dentist who performed the original root canal should not be reimbursed for the retreatment for the first 18 months. | 50% | 40% | |
| Root Resection/Amputation | |||
| Limited to 1 time per root per lifetime. | 50% | 40% | |
| Therapeutic Pulpotomy | |||
| Limited to 1 time per primary or secondary tooth per lifetime. | 50% | 40% | |
| Pulpal Therapy (resorbable filling) - Anterior or Posterior, Primary Tooth (excluding final restoration) | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Pulp Caps - Direct/Indirect – excluding final restoration | |||
| Not covered if utilized solely as a liner or base underneath a restoration. | 50% | 40% | |
| Pulpal Debridement, Primary and Permanent Teeth | |||
| Limited to 1 time per tooth per lifetime. This procedure is not to be used when endodontic services are done on same date of service. | 50% | 40% | |
| PERIODONTICS | |||
| Crown Lengthening | 50% | 40% | |
| Gingivectomy/Gingivoplasty | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Gingival Flap Procedure | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Osseous Graft | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Osseous Surgery | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Guided Tissue Regeneration | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Soft Tissue Surgery | |||
| Limited to 1 time per quadrant or site per consecutive 36 months. | 50% | 40% | |
| Periodontal Maintenance | |||
| Limited to two (2) periodontal maintenance in any 12 consecutive months, to a maximum of two (2) total prophylaxis and/or periodontal maintenance procedures in any 12 consecutive months. | 50% | 40% | |
| Full Mouth Debridement | |||
| Limited to 1 time per consecutive 36 months. | 50% | 40% | |
| Provisional Splinting | |||
| Cannot be used to restore vertical dimension or as part of full mouth rehabilitation, should not include use of laboratory based crowns and/or fixed partial dentures (bridges). Exclusion of labatory based crowns or bridges for the purposes of provisional splinting. | 50% | 40% | |
| Scaling and Root Planing | |||
| Limited to 1 time per quadrant per consecutive 24 months. | 50% | 40% | |
| Localized Delivery of Antimicrobial Agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. | |||
| Limited to 1 site per quadrant or 4 sites total per 12 consecutive months for refractory pockets, not in conjunction with scaling or root planing, by report. | 50% | 40% | |
| ORAL SURGERY | |||
| Alveoloplasty | 50% | 40% | |
| Biopsy | |||
| Limited to 1 biopsy per site per visit. | 50% | 40% | |
| Frenectomy/Frenuloplasty | 50% | 40% | |
| Surgical Incisions | |||
| Limited to 1 time per site per visit. | 50% | 40% | |
| Removal of a Benign Cyst/Lesions | |||
| Limited to 1 time per site per visit. | 50% | 40% | |
| Removal of Torus | |||
| Limited to 1 time per site per visit. | 50% | 40% | |
| Root Removal, Surgical | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Simple Extractions | |||
| Limited to 1 time per tooth per lifetime. | 80% | 70% | |
| Surgical Extraction of Erupted Teeth | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Surgical Extraction of Impacted Teeth | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Surgical Access, Surgical Exposure, or Immobilization of Unerupted Teeth | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Primary Closure of a Sinus Perforation | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Placement of Device to Facilitate Eruption of Impacted Tooth | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Transseptal Fiberotomy/Supra Crestal Fiberotomy, by report | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Vestibuloplasty | |||
| Limited to 1 time per site per consecutive 60 months. | 50% | 40% | |
| Bone Replacement Graft for Ridge Preservation - per site | |||
| Limited to 1 time per site per lifetime. Not Covered if done in conjunction with other bone graft replacement procedures. | 50% | 40% | |
| Excision of Hyperplastic Tissue or Pericoronal Gingiva | |||
| Limited to 1 time per site per consecutive 36 months. | 50% | 40% | |
| Tooth Reimplantation and/or Transplantation Services | |||
| Limited to 1 time per tooth per lifetime. | 50% | 40% | |
| Oroantral Fistula Closure | |||
| Limited to 1 time per site per visit. | 50% | 40% | |
| ADJUNCTIVE SERVICES | |||
| Analgesia | |||
| Covered when Necessary for one of the following reasons; toxicity to local anesthesia, mental retardation, Alzheimer's, spastic muscle disorders. | 50% | 40% | |
| Desensitizing Medicament | 50% | 40% | |
| General Anesthesia | |||
| Covered when Necessary for one of the following reasons: toxicity to local anesthesia, mental retardation, Alzheimer's, spastic muscle disorders. | 50% | 40% | |
| Local Anesthesia | |||
| Not Covered in conjunction with operative or surgical procedure. | 50% | 40% | |
| Intravenous Sedation and Analgesia | |||
| Covered when Necessary for one of the following reasons; toxicity to local anesthesia, mental retardation, Alzheimer's, spastic muscle disorders. | 50% | 40% | |
| Therapeutic Drug Injection, by report/Other Drugs and/or Medicaments, by report | |||
| Limited to 1 time per visit. | 50% | 40% | |
| Occlusal Adjustment | 50% | 40% | |
| Occlusal Guard Reline and Repair | |||
| Limited to relining and repair performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months. | 50% | 40% | |
| Occlusion Analysis - Mounted Case | |||
| Limited to 1 time per consecutive 60 months. | 50% | 40% | |
| Palliative Treatment | |||
| Covered as a separate benefit only if no other services, other than exam and radiographs, were done on the same tooth during the visit. | 100% | 90% | |
| Consultation (diagnostic service provided by dentists other than practitioner providing treatment.) | |||
| Not Covered if done with exams or professional visit. | 100% | 90% | |
| Gold Foil Restorations | |||
| Multiple restorations on one surface will be treated as a single filling. | 50% | 40% | |
| Occlusal Guards | |||
| Limited to 1 guard per 60 consecutive months and only covered if prescribed to control habitual grinding. | 50% | 40% | |
| Coping | |||
| Limited to 1 time per tooth per 60 consecutive months. Not Covered if done at the same time as a crown on same tooth. | 50% | 40% | |
| Inlays/Onlays – Temporary Crown/Crowns – Restorations/Retainers/ Abutments | |||
| Limited to 1 time per tooth per 60 consecutive months. Not Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes. | 50% | 40% | |
| Pontics | |||
| Limited to 1 time per tooth per 60 consecutive months. | 50% | 40% | |
| Retainer-Cast Metal for Resin Bonded Fixed Prosthesis | |||
| Limited to 1 time per tooth per 60 consecutive months. | 50% | 40% | |
| Pin Retention | |||
| Limited to 2 pins per tooth; not covered in addition to cast restoration. | 50% | 40% | |
| Post and Cores | |||
| Covered only for teeth that have had root canal therapy. | 50% | 40% | |
| Sedative Filling | |||
| Covered as a separate benefit only if no other service, other than X-rays and exam, were done on the same tooth during the visit. | 50% | 40% | |
| Stainless Steel Crowns | |||
| Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown - primary tooth, are limited to primary anterior teeth. | 50% | 40% | |
| IMPLANTS | |||
| Surgical Services |
Surgical placement of implant body (endosteal) & interim implant body, both eposteal and transosteal.
Implant removal, by report.
| Limited to one (1) time per tooth per 60 consecutive months. | 50% | 40% |
| Supporting Structures |
Prefabricated abutment, and custom abutments Limited to one (1) time per tooth per 60 consecutive months.
| Covered only when evidence of implant body surgically placed. | 50% | 40% |
| Single Crowns, Abutment Supported |
Porcelain ceramic, porcelain to metals, cast metals, titanium
| One (1) per 60 consecutive months if the previous crown is not serviceable and cannot be repaired. | 50% | 40% |
| Fixed Partial Denture, Abutment Supported |
Porcelain/ceramic FPD, porcelain fused to metals FPD, cast metals FPD, titanium crown FPD
| One (1) per 60 consecutive months if the previous crown is not serviceable and cannot be repaired. | 50% | 40% |
| Other Implant Services |
Repair prosthesis, repair abutment, implant removal
| Covered only when administered by a different provider. | 50% | 40% |
| FIXED PROSTHETICS | ||
| Fixed Partial Dentures (Bridges) | ||
| Limited to 1 time per tooth per 60 consecutive months. | 50% | 40% |
| REMOVABLE PROSTHETICS | ||
| Full Dentures | ||
| Limited to 1 per 60 consecutive months. No additional allowances for precision or semi-precision attachments. | 50% | 40% |
| Partial Dentures | ||
| Limited to 1 per 60 consecutive months. No additional allowances for precision or semi-precision attachments. | 50% | 40% |
| Relining and Rebasing Dentures | ||
| Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months. | 50% | 40% |
| Tissue Conditioning - Maxillary or Mandibular | ||
| Limited to 1 time per consecutive 36 months. | 50% | 40% |
| Repairs or Adjustments to Full Dentures, Partial Dentures, Bridges or Crowns | ||
| Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 time per consecutive 6 months. | 50% | 40% |
| ORTHODONTICS | ||
| Orthodontic Services | ||
| Services or supplies furnished by a Dentist to a Member and his or her Enrolled Dependent under age 19 in order to diagnose or correct misalignment of the teeth or the bite. | 50% | 50% |
| Appliance Therapy, Fixed or Removable | ||
| Limited to 1 time per 60 consecutive months. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances. | 50% | 50% |
| Cephalometric Film | ||
| Limited to 1 per consecutive 12 months. Can only be billed for orthodontics. | 100% | 90% |
&"Arial,Regular"APPENDIX G - OPTION V - PREMIER DPPO PLAN &"Arial,Regular"CONFIDENTIAL AND PROPRIETARY &"Arial,Regular"Page &P of &N
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