CIGNA DENTAL CARE (DHMO) PLAN HIGH OPTION

Cigna Dental DHMO High Option

Cigna Dental Care (DHMO) High Option

Schedule of Benefits

PATIENT CHARGE SCHEDULE

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This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.
This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You should verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.
Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees.
The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.
Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.
This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.
Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.
All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.
The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.

Office visit fee – (per patient, per office visit in addition to any other applicable patient charges)

Code	Procedure Description	Patient Charge

	Office visit fee	$0.00

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).

Code	Procedure Description	Patient Charge

D9310	Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)	$0.00
D9430	Office visit for observation – No other services performed	$0.00
D9450	Case presentation – Detailed and extensive treatment planning	$0.00
D0120	Periodic oral evaluation – Established patient	$0.00
D0140	Limited oral evaluation – Problem focused	$0.00
D0145	Oral evaluation for a patient under 3 years of age and counseling with primary caregiver	$0.00
D0150	Comprehensive oral evaluation – New or established patient	$0.00
D0160	Detailed and extensive oral evaluation - Problem focused, by report
	(limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)
D0170	Re-evaluation – Limited, problem focused (established patient; not post-operative visit)	$0.00
D0180	Comprehensive periodontal evaluation – New or established patient	$0.00
D0210	X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)	$0.00
D0220	X-rays intraoral – Periapical – First radiographic image	$0.00
D0230	X-rays intraoral – Periapical – Each additional radiographic image	$0.00

We appreciate your interest and look forward to speaking with you soon!

If you have an urgent or immediate need, please call us toll-free at (800) 733-7236.

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