Agmt78 California Dental Servic - Laserfiche WebLink

Browse Search

4.05 CDS shall pay or otherwise discharge 8 0 % of the Dentists' Usual, Customary and Reasonable fees or of the fees actually charged, whichever is less, for the following Crowns, Jackets and Gold or Cast Restorations Benefits: Crowns, Jackets and Gold or Cast Restorations will be provided when teeth cannot be restored with amalgam, synthetic porcelain or plastic restorations. 4.06 LIMITATION ON CROWNS, JACKETS AND GOLD OR CAST RESTORATIONS: The following limitation applies to Crowns, Jackets and Gold or Cast Restorations: Crowns, Jackets and Gold or Cast Restorations will be replaced only after five (5) years have elapsed following any prior provision under any CDS program. 4.07 CDS shall pay or otherwise discharge 8 0 % of the Dentists' Usual, Customary and Reasonable fees or of the fees actually charged, whichever is less, for the following Prosthodontic Benefits: Procedures for construction or repair of fixed bridges, partial or complete dentures. 4.08 LIMITATIONS ON PROSTHODONTIC BENEFITS: The following limitations apply to Prosthodontic Benefits: a} A patient shall be eligible for Prosthodontic Benefits only following such patient's continuous enrollment under this Contract for a period of months. b) Prosthodontic appliances, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have elapsed following any prior provision of such appliances under any CDS Contract, except when CDS determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement will be made of a prosthodontic appliance not provided under a CDS Contract only if it is unsatisfactory and cannot be made satisfactory, c) Implants (artificial materials implanted into or on bone or soft tissue), or the surgical removal of implants, are not benefits under this Contract. However, if implants are provided, CDS will allow the cost of a standard complete or partial denture toward the cost of implants and appliances constructed in association therewith. If CDS makes an allowance toward the cost of implants, CDS will not pay for any replacement appliance placed within five years thereafter. d) CDS will pay the applicable percentage of the Dentist's fee for a standard cast chrome or acrylic partial denture or a standard complete denture, up to the maximum fee allowance which is at least the Prevailing Fee for a standard denture. The maximum allowance is revised periodically as dental fees change. Any den- ture and/or related service for which a charge is made which exceeds this allowance is considered an optional service, and the patient is responsible for the portion of the Dentist's fee in excess of the CDS allowance. 4.09 CDS shall provide Orthodontic Benefits in accordance with the Orthodontic Rider attached hereto as Appendix "C". 4.11 GENERAL LIMITATIONS-OPTIONALSERVICES If an Etigible Person selects a more expensive plan of treatment than is customarily provided, CDS will pay the applic- able percentage of the lesser fee and the patient is responsible for the remainder of the Dentist's fee. For example: gold crown where a silver filling would restore the tooth, a precision denture where a standard denture would suffice. -6-