HUSKY Dental

BeneCare manages and provides dental services to CHNCT members. Members are assigned or may choose any Primary Care Dentist (PCD) within BeneCare’s provider network. A PCD may be either a Pediatric or a General/Family Dentist. As a care manager, the PCD will provide 24-hour emergency coverage, review all reports from specialists, ensure continuity of dental care, and coordinate all dental services rendered to the member. A complete listing of participating dental providers can be found in CHNCT's Provider Directory. Specialty dental services may require a referral and prior authorization. For any questions regarding authorization, claims submission or claims payment, please contact BeneCare at 1-800-843-4727.

Benefit Descriptions

FOR HUSKY A & HUSKY B

Dental Services Covered and Limitations

Diagnostic Services
1. Home Visits
2. Radiographs
  1. Intraoral, complete series (full mouth) consisting of at least ten (10) periapical films excluding bitewings, limited to once during every three (3) year period
  2. Bitewing films, only once during any six (6) month interval per member
  3. Periapical films; problem specific associated with a tooth number
3. Oral Examinations, with the following limitations:
  1. Initial comprehensive oral exam includes a complete history work-up and is limited to one per patient, per provider in a three year period
  2. Periodic Oral Exam, initiated 6-months subsequent to an initial oral exam and may be utilized every 6-months thereafter
  3. Emergency Oral Exam, may be used when diagnosing a palliative (emergency) treatment
Preventive Services
1. Prophylaxis, once every 6-months per member. Prophylaxis includes cleaning, supra and sub gingival scaling, and polishing teeth
2. Fluoride treatment for children under 21-years of age will be paid for no more than twice a year (at 6-month intervals) per member. Once each six (6) months for adults with radiation and chemotherapy.
3. Space Maintainers – Once per 365 days
4. Night guard, one per member
5. Pit and fissure sealants
  1. For children ages 5 through 16 only. Prior Authorization is required for children under age 5 and persons over age 16.
  2. Once in a five year period per tooth
  3. Limited to first and second permanent molars
Restorative Services (HUSKY B members have a $50 allowance per procedure per member but no more than an aggregate allowance for all such procedures of $250 per continuous eligibility period on bridges, crowns, root canals, full or partial dentures or extractions.)
1. Fillings
  1. Permanent fillings using silver amalgam or composite resin material (anterior and posterior teeth) are limited to three (3) surfaces per year.
  2. Temporary sedative fillings, only when done to treat dental pain requiring emergency treatment
  3. Multiple fillings on a single surface will be considered a single filling
2. Crowns, of the following materials and only in those cases where the breakdown of tooth structure is excessive:
  1. Under age 21 – all permanent teeth except 3rd molars
3. Posts & Cores – Not for cosmetic reasons/only to restore coronal form and function.
Endodontics with the following limitations:
1. Root canal therapy and/or apicoectomy shall be covered for children under age 21, all but 3rd molars, no primary teeth.
2. Apexification (not including root canal treatment but includes all visits to complete the service)
Prostodontics with the following limitations:
1. Removable, complete and partial denture prostheses only
2. Replacement of existing dentures, only once in any five (5) years from the date of placement of the existing dentures. Exceptions will be considered where the absence of dentures would create an adverse condition jeopardizing the patient’s medical health
3. Reline or rebasing existing dentures not more than once in any two (2) year period
4. Denture labeling, for patients in long term care facilities only.
Dental Surgery with the following limitations:
1. Suture of laceration of the mouth, in accident cases only and not cases incidental to and connected with dental surgery
2. Gingivectomy, for severe side effects caused by medication
3. Replant avulsed anterior tooth, not in conjunction with a root canal
4. Bone grafts, mandible, restricted to the placement of bone previously removed by radical surgery procedures
Edodontia (extractions)
Orthodontics – (HUSKY B has an benefit maximum of $725 per orthodontia case.)
1. Orthodontic screening, One (1) per member
2. Orthodontic consultation, one (1) per member
3. Preliminary diagnostic assessment casts/study models, one (1) per member
4. Comprehensive Diagnostic Assessment (CDA), one (1) per member
5. Initial appliance, one (1) per member
6. Active treatment, including retention, up to a maximum of thirty (30) months per member
7. Retainer appliances, may be replaced only once per dental arch for the same member regardless of the reason
8. Orthodontic services are limited to members under twenty-one (21) years of age
9. All orthodontic services must be provided by a qualified dentist
  1. A provider that is an orthodontist in accordance with section 20-106a of the Connecticut State Statutes
Outpatient Hospital Dental Services
1. Performed by appropriate licensed dental personnel
2. Services performed within the scope of provider’s profession
Alveolectomy (Alveoplasty)
1. Covered only when an edentulous ridge is involved (not in conjunction with extractions)
Patient Management Fee
1. A fee may be claimed in connection with dental services to individuals who, because of cognitive disabilities, are limited in their ability to understand directions and thus require additional time on the part of the dentist to deliver services
2. In order to access the fee, the provider must satisfy two documentation requirements
  1. The provider must document the specific diagnosis in the patient’s record. A diagnosis of moderate, severe, or profound mental retardation will satisfy this requirement
  2. The provider must have in the patient’s record the signature of a physician or a professional staff member of the Department of Mental Retardation, attesting to the authenticity of the diagnosis
3. General Surgical Anesthesia

Non-Covered Services and Materials

The following services/materials are not covered under either HUSKY A or HUSKY B benefit plans and are NOT reimbursable by BeneCare Dental Plan and/or CHNCT:

Fixed bridges
Periodontia
Implants
Transplants
Cosmetic dentistry
Vestibuloplasty
Unilateral removable appliances
Partial dentures where there are at least eight (8) posterior teeth in occlusion, and no missing anterior teeth
Restorative procedures to deciduous teeth nearing exfoliation
Extractions on deciduous teeth nearing exfoliation, except in those cases where over-retention is a documented problem or in conjunction with an emergency
The following surgical procedures are not covered unless orthodontia has been prior authorized:
1. Surgical exposure of impacted or unerupted teeth for orthodontic reasons
2. Osteoplasty (osteotomy) of maxilla and/or other facial bones for midface hypoplasia or retention, without bone graft
3. Cancelled office visits or appointments not kept
4. Admitted services or any inpatient dental services performed by the admitting dentist if the admission was not approved by BeneCare as medically necessary
5. Orthodontia for members 21 years of age or older

Prior Authorization Requirements

BeneCare requires that certain services within the list of defined covered services be predetermined in advance of treatment being provided. The include:

All proposed orthodontic treatment
Non-emergency anterior endodontics
Non-emergency posterior endodontics, which is subject to the exclusions and limitations noted in that section of the HUSKY A description
Submissions for all single crowns; posterior crowns are a non-Medicaid covered service, except as specifically noted in the HUSKY A section on covered services
Partial dentures

Contracting and Credentialing

BeneCare Dental Plan is responsible for credentialing and contracting each dental provider in their network.

BeneCare Contacts

Inquiries to BeneCare are important and must be responded to without delay. If you have any questions for BeneCare, please make note of the following phone numbers:

Member Services: 1-800-843-4727
Claim Inquiries: 1-800-843-4727
Provider Services: 1-800-995-9943

Claim Submission

BeneCare Dental Services
615 Chestnut Street
Suite 1001
Philadelphia, PA 19106

For questions on participation, authorization, claims submission, payment, or to identify a participating provider in a particular area call the BeneCare customer service line at 1-800-843-4727.

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HUSKY Dental