Rand water medical scheme dental policy and procedures protocol 2016 General Principles



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RAND WATER MEDICAL SCHEME DENTAL POLICY AND PROCEDURES PROTOCOL 2016
General Principles

  • All dental procedures are covered as per the description of Rules for the specific Scheme option concerned.

  • The Clinical Protocols of Supplementary Health Services will take precedence and Rand Water Medical Scheme tariff will apply.

  • All treatment rendered by a dental specialist is regarded as Specialised treatment regardless of the treatment with the exception of treatment defined as falling within PMB.

  • All specialised dentistry and hospitalisation for dental procedures are subject to pre-authorisation by Supplementary Health Services before treatment commences, except in the case of emergency hospital admissions. Such authorisation must be obtained within 48 hours or the following working day thereafter.

  • A written authorisation is not a guarantee of payment and is issued subject to available benefit at the time when the claim/s is received. The authorisation includes a summary of benefit allocation.

  • Hospital authorisations are only valid for one (1) month and all other authorisation are valid for three (3) months.

  • Benefit verification applicable to Hospitalisation, consumables, theatre and anesthetist cost must be obtained from the Scheme’s Hospital Managed care organisation


Orthodontic treatment

  • Benefits are only applicable to functional treatment for beneficiaries below the age of 18 years

  • Benefits for all orthodontic treatment is subject to prior appraisal using the Index of Complexity, Outcome and Need (ICON Copyright University of Wales College of Medicine) other such recognised clinical index as determined by Supplementary Health Services.




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

  • Removable appliances are limited to 2 appliances.

  • Re-treatment of orthodontics is not covered.

  • Lost appliances repair, remounting or replacement of fixed orthodontic brackets is not covered. Lingual orthodontics or ceramic orthodontics brackets are not covered. Invisible retainer material is not covered.

  • Re-treatment of orthodontic cases is not covered and for transferred cases to a next provider; only the balance of the treatment plan will be covered.

  • Retainers are limited to one per jaw.

  • Orthognathic and associated hospitalisation is not covered. Preparatory orthodontic therapy prior to orthognathic surgery will be limited to the treatment required to achieve an outcome without such surgery.


Apisectomies

Benefit will not be considered unless a reasonable attempt has been made to drain the peri-apical infection via endodontic procedures and through re-treatment where applicable.


Periodontics

Benefits for periodontal disease management is limited to conservative (non-surgical) management once every 2 years and is subject to pre-authorisation using the CPITN index. Surgical periodontal treatment is not covered.


Procedure Limitations

  • Only Dental Therapist registered on the provider network will be covered.

  • No benefits for implants and all procedures associated with implantology in and out of hospital on all option.

  • Benefits for dental “check-ups” as described in the schedule under code 8101 or 8104 are allowed once per six-month period per dependant.

  • Benefits for conservative dental restorations/fillings are available where such fillings are clinically indicated, and will be granted once per tooth in a 3 year period.

  • More than 4 fillings per member per year where clinically motivated, must register on the dental care programme and assessed by Supplementary Health Services.

  • In the case of fillings on posterior teeth (molar and pre-molars) the Supplementary Health Services tariff for amalgam fillings will apply, regardless of the material used.

  • Preventive visits are limited to one every six months. More regular visits will attract benefit once disease risk has been clinically motivated and assessed by Supplementary Health Services.

  • Fissure sealants are covered once every 2 years, up to 18 years only on permanent molars and pre-molars.

  • Extra-oral radiograph only for orthodontic treatment planning and removal of impacted teeth for beneficiaries above 18 years.

  • One extra-oral radiograph per year, except for orthodontic treatment planning where 2 extra-oral radiographs will be covered.


Hospitalisation and Intravenous Sedation

  • Hospitalisation or Intravenous Sedation for dentistry is not automatically covered and is subject to pre-authorisation where the following protocols will apply:

  • Hospitalisation cover is provided for children below the age of 7 years when the treatment envisaged is of such a nature that it cannot performed without a general anaesthesia and will only be considered after other forms of sedation were administered unsuccessful. Fissure sealant, fluoride treatment and polishing of teeth for children below 7 years will not be authorised in hospital.

  • Multiple restorative visits to theatre for children below the age of 7 years will not be covered i.e. a single hospital visit should suffice to stabilise the dentition there after routine dental treatment and preventative dentistry will only be covered in the dental rooms.

  • Removal of impacted teeth will only be covered when the tooth is associated with pathology or severe pain and the removal of such a tooth cannot be reasonably performed outside of hospital as may be radiologically verified and not for orthodontic reasons. Single impaction extraction or soft tissue impactions will not be covered in Hospital.

  • Theatre visits for persons above 7 years for conservative dentistry and extractions will not be covered. The requirement of a sterile facility is not on its own an acceptable reason for hospitalisation for dental treatment.

  • Hospitalisation cover will only be considered where an underlying medical condition increases the risk of treating in the rooms or indicates that higher level of care is required. Benefit only in cases of accidents, injury, congenital abnormalities and oncology related procedures only (PMB).

  • Apicectomies on premolar canine, anterior and 3rd Molars procedures in hospital will not be considered for benefit unless retreatment of root cannel has been attempted and is restricted to molars and lower pre-molars.

  • Hospitalisation benefits are not available for dental implantology and associated procedures e.g. sinus lift, bone harvest and tissue regeneration procedures on all options


The following will not be covered in hospital:

  • Dentectomies

  • Frenectomies

  • Conservative dental treatments e.g. fillings on adults, fissure sealant, fluoride treatment and polishing of teeth

  • Periodontal procedures are not covered in hospital

  • Periodontal surgery

  • Genioplasty

  • Implants

  • Gingivectomy

  • Root canal therapy


Patient anxiety control

Where a dental practitioner requires a medical colleague to administer sedatives intravenously (not general anaesthetic) to assist in difficult cases in the dental rooms, the fee charged by the second professional will be covered by the scheme only if pre-authorised by Supplementary Health Services. Such authorisation will only be considered if the administering nitrous oxide (laughing gas) has been unsuccessful.

No limits are placed on the use of oral sedatives or nitrous oxide administered by dental practitioners in their rooms.
Restrictions and Exclusions

The treatments and procedure codes listed below are not covered by the scheme. The member is liable for the total cost of these procedures. In the event of a dispute regarding exclusions and benefits, the rules of Rand Water medical scheme will prevail.



  • Cosmetic dentistry

  • Bite plate below 25 years old

  • Mouthwash and toothpastes

  • Fissure sealants on patients older than 18 years and younger than 5 years

  • Professionally applied topical fluoride in adults 18 years and above

  • Oral/facial image of dentist work not covered only for orthodontics

  • Perio chip

  • Ozone therapy

  • Therapy of healed extraction sites

  • Vascular surgery for treatment of headaches

  • Oral appliance or the ligation of temporal arteries for treatment of headaches

  • For multiple charges of desensitising, resin or medicament, only application of desensitising medicament per visit will apply once-off

  • Desensitising, resin or medicament, will not be covered during the same visit as application of topical fluoride

  • Restorative treatment of attrition or abrasion

  • Tariff for amalgam fillings will apply, regardless of the material used

  • Endodontic procedures are not covered on third molars (wisdom teeth) or on primary teeth

  • Endodontic re-treatment is not covered within 2 years of initial endodontic treatment

  • Emergency root canal / Pulp removal (pulpectomy) charged on the same day as complete therapy

  • Rubber dam per arch

  • Crowns used to restore teeth for cosmetic reasons

  • Crowns where the tooth has been recently restored to function

  • Composite or porcelain veneers

  • Laboratory fabricated crowns are not covered on primary teeth or third molars (wisdom teeth)

  • Crowning of teeth involving failed R.C.T

  • Temporary /provisional and emergency crowns including lab costs

  • Acrylic crowns, including laboratory aspects, placed for any reason are excluded from benefits

  • Fixed prosthodontics (crowns) where a reasonable attempt has not been made to restore/replace the tooth conservatively

  • Fixed prosthodontics where the members mouth is periodontally compromised

  • Fixed prosthodontics used to restore teeth for cosmetic reasons

  • Fixed prosthodontics used to repair occlusal wear (teeth damaged due to bruxism) erosions or fluorosis

  • Fixed prosthodontics where the tooth has been recently restored to function

  • Benefit for the cost of metal would be in accordance to the tooth type

  • Cost of gold, precious metal, semi-precious metal and platinum foil

  • For metal free crowns, metal substitute coping material will be paid at the same rate as metal

  • Metal substitute coping material for laboratory cost for crowns

  • Lab costs where the associated dental procedure is not covered

  • Cantilevers bridges

  • Pontics on second molars

  • Inlays and onlays regardless of material used, will not be covered

  • Diagnostic dentures

  • Basic denture rate would apply to Complicated Dentures

  • High impact acrylic

  • Metal base to full dentures

  • Diagnostic models (Study models-unmounted) will only be covered with orthodontic treatment

  • Adult orthodontics over 18 years

  • Orthodontics to align teeth for cosmetic reasons

  • Orthodontic re-treatment

  • Orthodontic retainer/fixed/removable appliance repairs

  • Lingual orthodontics/ceramic brackets

  • Diagnostic setup (orthodontics)

  • Orthognathic (jaw correction) surgery and related hospital costs

  • Osteotomy

  • Surgical periodontal services

  • Gingivectomy

  • Dentectomies in hospital

  • Frenectomies in hospital

  • Removal of asymptomatic wisdom teeth

  • Fillings, extractions and root canal therapy in hospital over age of 7 years

  • Preventative dentistry procedures in hospital

  • Assistant fee to be assessed on individual cases

  • MRI and CAT scans for any dento-alveolar procedures will not be covered

  • Extra-oral radiograph only for orthodontic treatment planning and removal of impacted teeth

  • Dental implants in or out of hospital and associated surgical procedures listed below are excluded,

  • Implant tooth replacement all phases

  • Cost of implant components

  • Bone augmentation, or tissue regeneration or cost of bone regeneration material

  • Sinus lifts



OUT OF HOSPITAL DENTAL BENEFITS 2016


BASIC DENTISTRY

OPTION A - BASIC DENTISTRY

100% of scheme tariff



OPTION B PLUS DENTAL SERVICES

100% of scheme tariff



Dental Consultation( Annual check-up)

2 annual checkups per beneficiary, 1 every 6 months

Dental Therapist Only registered network providers.

2 annual checkups per beneficiary, 1 every 6 months

Dental Therapist Only registered network providers.

Restorations/fillings (Amalgam and Resin)

More than 4 fillings per member per year must be motivated and case management for extensive dental restorations will apply and must register on the dental care programme



Benefits for fillings are available where such fillings are clinically indicated, and will be granted once per tooth in a 3 year period.

Benefits for fillings are available where such fillings are clinically indicated, and will be granted once per tooth in a 3 year period

Diagnostics

Intra-oral radiographs complete series not covered 4 x Peri-apical X-Rays annually per member or 2 x Bite wings once a year


Intra-oral radiographs complete series not covered 4 x Peri-apical X-Rays annually per member or 2 x Bite wings once a year



Preventative Dentistry


Scale and polish once every 6 months

Fluoride treatment only members between 5 & 18 years




Scale and polish once every 6 months

Fluoride treatment only members between 5 & 18 years





SPECIALISED DENTISTRY

OPTION A - SPECIALISED DENTISTRY

100% of scheme tariff



OPTION B PLUS DENTAL SERVICES

100% of scheme tariff subject to the above Dental Services Limit



Crowns and Bridges

Pre-authorisation and X-Rays are required



2 crowns or 2 bridge units per family per year.

Benefit for crowns are granted once per tooth per 5 years



1 crowns or 1 bridge unit per family per year.

Benefit for crowns are granted once per tooth per 5 years



Dentures

Subject to pre-authorisation and treatment protocols.



1 set of full ,or upper, or lower plastic denture every 4 years Relines, rebase, soft base every 2 years

Metal framework every 5 years

Partial denture every 3 years


1 set of full ,or upper, or lower plastic denture per beneficiary every 4 years or 1 partial plastic denture per jaw per beneficiary every 4 years Relines, rebase, soft base every 2 years Partial denture every 3 years

Orthodontics Limited to beneficiaries below the age of 18 years and apply to functional treatment only Pre authorisation required, including retainers

Pre-authorisation is required for orthodontic treatment subject to available specialised dentistry limit

Pre-authorisation is required for orthodontic treatment subject to available specialised dentistry limit

Periodontics Pre-authorisation required

Restricted to non-surgical, root planning and periodontal procedures only

Restricted to non-surgical, root planning and periodontal procedures only

Endodontic therapy

(Root canal treatment)

3 Peri-apical X-Rays covered, 8132 Pulp removal/ emergency root canal treatment not allowed on same day as root treatment



Pre-authorisation is required

Direct or indirect pulp capping 8301/8303 excluded from benefit

Root canal treatment on primary and wisdom teeth excluded from benefit


Pre-authorisation is required

Direct or indirect pulp capping 8301/8303 excluded from benefit

Root canal treatment on primary and wisdom teeth excluded from benefit





RAND WATER DENTAL BENEFIT 2016



IN HOSPITAL DENTAL BENEFITS





OPTION A

OPTION B PLUS

Overall in Hospital Limit (OHL)

R 1,593,000 per family

R 780,000 per family

Dental Hospitalisation

Subject to pre-authorisation



100% of scheme tariff Subject to Overall Annual Hospital Limit R1,593,000 per family per annum
Benefit for dental services in hospital is limited to trauma, cancer or PMB cases only
Benefit is strictly only for cases of children below 7 years

Dental Provider account is payable from Conservative Dentistry limit and restricted to restorative procedures only
Multiple hospital admissions will not be covered and will only be authorised once in a lifetime

No benefit for preventative procedures in hospital

100% of scheme tariff Subject to Overall Annual Hospital Limit R780,000 per family per annum
Benefit for dental services in hospital is limited to trauma, cancer or PMB cases only
Benefit is strictly only for cases of children below 7 years

Dental Provider account is payable from DENTAL SERVICES limit and restricted to restorative procedures only
Multiple hospital admissions will not be covered and will only be authorised once in a lifetime

No benefit for preventative procedures in hospital

Maxillo-Facial and Oral/Dental Surgery
Subject to preauthorisation and clinical appropriateness and protocol


100% of scheme tariff
Hospitalisation and anaesthetist cost from (OHL)

Dental Provider account is payable from Maxillo Facial and Oral Surgery limit


Benefit only for removal of symptomatic impacted wisdom teeth (3rd molars) associated with pain and pathology, only if pre-authorised as a day case



100% of scheme tariff
Hospitalisation and anaesthetist cost from:

LIMIT: R12,800 per family per annum
Dental Provider account is payable from Maxillo Facial and Oral Surgery limit
Benefit only for removal of symptomatic impacted wisdom teeth (3rd molars) associated with pain and pathology, only if pre-authorised as a day case



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