Additional charge per tooth/unit for crowns, inlays, onlays, post $150.00 and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Different codes may be used to describe these covered procedures. 0000026124 00000 n 856631c 11/21 A3O09 . 0000027741 00000 n 92249 909351 08/17 B1I09 B1I09 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and . 0000011915 00000 n The contracted fee schedules vary by network dentist. U\$6hXttOg}wuNNc0t8a1+v3ij9)&@^WS1m;h=RXY|v+r=u\3+=Ih ]?JXO4oK"I-8IiU 6vi@xC{zGtB" E0bM5eu|nGE yl 0000012659 00000 n Patient Charges) Office Visit Fee $5.00 Diagnostic/Preventive - Oral Evaluations are Limited to a Combined Total of 4 of the Following Evaluations During a 12 Consecutive Month Period: Periodic Oral Programs and Initiatives (CCF, DLP, ISYLP, Career Pathways), DC Government Benefits Enrollment Instructions, UnitedHealthcare Choice Open Access Plan Summary, SmartBenefits Enrollment Application & Change Form, Temporary Continuation of Coverage Benefits Enrollment Form, Health Insurance for Employees Hired Before October 1, 1987, Health Insurance Premiums for Employees Hired on or After October 1, 1987, DCEHBP Temporary Continuation of Coverage (TCC) Premiums, How to Enroll in Your DC Government Benefits, Coronavirus (COVID-19) Resources for DC Government Employees, Electronic District Personnel Manual (eDPM), Electronic-District Personnel Manual (E-DPM), Whistleblower Protections and Obligations, Sexual Harassment Prevention Officer Directory, Human Resource Officer - Advisor Directory, 2023 Cigna Dental HMO Patient Charge Schedule, 2022 Cigna Dental HMO Patient Charge Schedule, 2021 Cigna Dental HMO Patient Charge Schedule. 948550 09/20 DENTAL INSURANCE THAT FITS Cigna Dental Care/DHMO Plan MTI09 PLAN HIGHLIGHTS IN-NETWORK Adult cleaning (two per calendar year - each at $0) $0 Child cleaning (two per calendar year - each at $0) $0 Periodic oral evaluation $0 Comprehensive oral evaluation $0 0000009930 00000 n %J) Ca:[LqXha fJ:fz6OPXc" 0000013184 00000 n "u+t&6_I $9mt9yzLHLHLHmQNa-AATQ"YjtNZc ).`xPDLP All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The fee policy means that Delta Dental's payment to participating dentists is based on the lesser of your submitted fee or the maximum fee that Delta Dental approves for a given procedure in a given region of the state for all Delta Dental-covered patients. cigna dental care (*dHMO) patient cHarge scHedule This Patient Charge Schedule describes the benefits of your dental plan and includes a list of covered procedures, and coinsurance percentage or copay for each covered procedure. 0000047828 00000 n 0000007475 00000 n CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE . hb```f`` 0000007481 00000 n 92260.a - 2 - CIGNA DENTAL CARE PATIENT CHARGE . How often does a dentist change network? For further information on Consultations and all other information on how accredited practitioners should interact with Cigna, in relation to services that may not be eligible for reimbursement, please read ourTerms and Conditions section here. All practitioners should advise Cigna members of the costs of any treatment (including consultations) being provided. *Indicates required field. %PDF-1.5 % 0000014082 00000 n Same day in-office CAD/CAM CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (W1-09 AZ) - 6 - 115 0 obj <>stream Health Insurance Premiums . 2021 Cigna Spotlight Event FAQ's Dental Customer Support (Hover over each logo to link to access website) Cigna Customer Support: 1.800.244.6224 1.866.611.8005 . dWR)]gP{ey01KGs9}eV}m#lVSfi7Gph Discuss your options and increased financial obligations with your dentist. UnitedHealthcare Choice Open Access Plan Summary. 92249.a - 2 - CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (W1-09) 0000023411 00000 n Cigna Fee Schedule Cigna Fee Schedule We expect all accredited Cigna providers to abide by The Cigna Fee Schedule, the schedule contains fair and reasonable maximum fees for Surgery and Anaesthesia, as well as guideline fees for Initial and Follow up consultations. L1I09 Code Procedure description L1I09 D0364 Cone beam CT capture and interpretation with limited field of view - less than one whole jaw (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per Cigna DHMO insurance plan features 3 SmartBenefits Enrollment Application & Change Form. Porcelain, if used on molar teeth, will be charged to the 66 59 % 0000003252 00000 n The American Dental Association may periodically change CDT Codes or definitions. 0000003348 00000 n 0000021133 00000 n 0000037369 00000 n 0000030031 00000 n 0000044371 00000 n hA 04s\GczC. CIGNA Dental Care (*DHMO) . "I+3o?`13}o+BY5k2\Ivw_G>U`o|V9~BxX!\NPe6 IyVD$9I8 adM::|G_,?t{C%-sM0 s4w7mmV"4hUkV%G67Cku{[Ya|uXtJ3\9U743),fKe&Y#6rPFtEixYzQsyk_,d_d>c(u#,rq m|XO?X 0'!$GSx2D 0QY9($ GENERAL DENTIST FEE SCHEDULE ALL PROCEDURES Effective from 06/01/2022 D1351 Sealant - Per Tooth $36 D1352 Preventive Resin Restoration In A Moderate To High Caries Risk Patient - Permanent Tooth $35 D1353 Sealant Repair - Per Tooth $35 D1354 Interim Caries Arresting Medicament Application - Per Tooth $29 0000014773 00000 n Cigna dental Care (*dHMO) . 92249 856609 02/13 L1-09 L1-09 cigna dental care (*dHMO) patient cHarge scHedule This Patient Charge Schedule lists the benefits of the Dental Plan including 0000003825 00000 n 0000009963 00000 n 0 0000008684 00000 n 0000059794 00000 n 0000047327 00000 n 10574 0 obj <> endobj 0000007842 00000 n dentist and is calculated based on the network dentist's contracted fee schedule, which is the amount Cigna agrees to pay dentists for their services. 0000047246 00000 n ^ 0000005847 00000 n 0000029880 00000 n 0000086554 00000 n 0000018616 00000 n 6 0 obj The American Dental Association may periodically change CDT Codes or definitions. 0000011147 00000 n However, this may be reviewed in the future and you should regularly check this website for updates. For premiums to remain affordable, practitioners, private facilities and health insurers need to work together to provide quality private healthcare at a reasonable and affordable price. 0000037577 00000 n 6 0 obj 0000009819 00000 n 0000061883 00000 n 0000047736 00000 n 0000060301 00000 n than the limitation allows, Cigna Dental will waive the applicable limitation. xZr7}W1a}rdvmQb*/#rD"!iCmM$>}|>3[S3/C/~:[}>ffgfsC_zK?o^}K7JU }s{7iWaV6Zp5Q4w j} GSyKF.Yt.`uUb56{:7.o8nRxitYunU+Not~\0:%~` Z;[@%re7?:w i&;_v[w7=}ohv.WZ0'eX27*}& Gm_j@v\m*,b6 durPt. Patient Charge Schedules are available to CIGNA Dental Care members only. 0000006418 00000 n endstream endobj startxref 'mec`PcsPFZ%5&: {8Fen cS 3@ %PDF-1.5 % 0000003434 00000 n 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. 92249 856612 02/13 K1-V9 K1-V9 cigna dental care (*dHMO) patient cHarge scHedule This Patient Charge Schedule lists the benefits of the Dental Plan including 10597 0 obj <>/Filter/FlateDecode/ID[<0F3F0D1BE2BD3847B9BF5CE826221B8D>]/Index[10574 51]/Info 10573 0 R/Length 105/Prev 385298/Root 10575 0 R/Size 10625/Type/XRef/W[1 2 1]>>stream Sorry, you need to enable JavaScript to visit this website. Use this form to request a CIGNA Dental Care patient charge schedule. 0000002304 00000 n hb```b``{% @1v(`;af. 0 Mental health: what health insurance can do for the emotional wellness of employees of SMEs, Embracing the digital age within healthcare, Tips for selecting a dental plan for your business, Addressing a 5 point workplace cancer strategy. ***It is important to note that, in order to support both its Members and Providers during the pandemic, Cigna has decided to reimburse remote consultations at the same level as face to face; subject to clinical appropriateness. "a\[x3A LN 00 + endstream endobj startxref 0 %%EOF 230 0 obj <>stream 0000001476 00000 n 92249.a - 2 - CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1-09) %PDF-1.3 % #EZ-6Pt;K,ZR V\evsag1!4IO)n .XXA1a,pa-V. 199 0 obj <>stream 0000002374 00000 n xZ]s|a? *O|uQ|J\DBb)oL@JCvrYmvggzzvyral=yuu@gv/geangu^kDZ,2n^x}V'cV5!3W#XQf3?6%c 0000015076 00000 n 0000046987 00000 n Vision Plan Summary. Cigna Dental HMO Patient Charge Schedule. Read important information about our fees including certain procedures, unlisted, bilateral and multiple procedures, anaesthesia and sedation, standby fees and the use of second specialists. Why take out a health insurance policy for employees at your SME? costly service, the fee listed on the Patient Charge Schedule will not apply. <]/Prev 575455>> .6#MoM}^eZ%E6a2x\r,dhWIj-z9R:G(8rp0\[P{ K^|b^h8@/mt(twG**yea{_r_T#v5B:-k. 0000080253 00000 n Office visit fee $0.00 Diagnostic/preventive - Oral evaluations are limited to a combined total of 4 of the . 0000003547 00000 n startxref trailer The American Dental Association may periodically change CDT Codes or definitions. H10+U-a`1';vfk@Ze\b 0000010574 00000 n Their key initiative is to develop a common set of codes and descriptions across the UK private healthcare sector. 20p@didagr99)1&^Jo,,oYN(k^,ny'9]p\*uCJx.6%/tqWnszJ&m2^*}y"k7WP/CK// hb```,V!] 0000002804 00000 n stream When you meet your annual deductible and satisfy any waiting periods, you pay a coinsurance (a portion of covered charges), and the dental plan pays the rest (up to the yearly or lifetime dollar limit of the plan). %PDF-1.3 % ?2h` h If my dentist were to drop . 0000016764 00000 n 0000017737 00000 n 0000012824 00000 n hb```a``d`e``f`@ +s,`@_e%4{0G(tlXp=e|8Cwfg{YfMasP"{_EJ[xm!O@GYr%#PXR7JwG>0E'Bgu6A2NPI[Xw=./Q}9nQYCh$%cc4 X(i@e Log in to our provider portal. Maintenance Organization (DHMO) Schedule of Benefits Effective January 1, 2021 . 0000004408 00000 n Of the rest of the land, 2.93 km 2 (1.13 sq mi) or 19.3% is settled (buildings or roads), 0.13 km 2 (32 acres) or 0.9% is either rivers or lakes and 0.14 km 2 (35 acres) or 0. . 0000079419 00000 n 0000040004 00000 n 0000040333 00000 n And a healthy body. 0000058952 00000 n Important Highlights This P atient Char ge Schedule applies only when c overed dental servic es are performed by your Network Dentist, unless otherwise authorized 0000013658 00000 n 0000047037 00000 n %PDF-1.6 % %PDF-1.3 Here are a few benefits and limitations to consider when evaluating a DHMO plan: Benefits Lower premiums than PPO plans or other types of dental insurance plans No deductible Set copayments; often minimal or no copayment for diagnostic and preventive care Typically, no annual maximum for covered benefits Limitations Smaller dentist network size J('5&% 0000027388 00000 n hb```a``}xAb@Y(@ DnbeN`!@vt@:M\I7'O 3nN*:J{>f X8Et$>xe0Y#duR.+b,k^Nv[CsLm&jF5Db4juU Hh>) $"x# q7?0 vw 0000043896 00000 n 0000001356 00000 n %PDF-1.6 % The application of local anesthetic is covered as part of your dental treatment. All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. 0000047772 00000 n There are no deductibles to pay before coverage begins, no annual dollar maximums on covered services, no claim forms, and no waiting periods. 0000010068 00000 n 0000012346 00000 n "` h`E(Zb3q"D"cbC. 0000012213 00000 n We expect all accredited Cigna providers to abide by The Cigna Fee Schedule, the schedule contains fair and reasonable maximum fees for Surgery and Anaesthesia, as well as guideline fees for Initial and Follow up consultations. 0000038912 00000 n Dentist may charge an additional fee not to exceed $150.00 in addition to the listed The CCSD schedule contains industry standard codes for surgical procedures and diagnostic tests in UK private healthcare. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 0000048491 00000 n Search the Fee Schedule by entering a code or keyword. 0000027140 00000 n % Cigna Dental Care Patient Charge Schedule (P6XV0)-2-Code Procedure Description Patient Charge. startxref 0000002658 00000 n 0000021775 00000 n 0000033062 00000 n Please use the search function to calculate your fees. 0000037057 00000 n 66 0 obj <> endobj 0000080139 00000 n 0000004072 00000 n 0000048422 00000 n 0000008121 00000 n 0000059263 00000 n 0000086632 00000 n 0000002700 00000 n 0000078060 00000 n Due to evolving medical practice, The Cigna Fee Schedule is reviewed periodically and therefore, complexities and/or fee values of procedures may change, maximum procedure fee reimbursement could go up or down. Do the new Total Care DHMO plan and the Cigna DHMO plan use the same network? %%EOF Different codes may be used to describe these covered procedures. CIGNA DENTAL CARE PLAN PATIENT CHARGE SCHEDULE (G1-V9) 92249.b - 3 - D0240 X-rays intraoral - Occlusal radiographic image $0.00 0000001917 00000 n 0000002140 00000 n 0000000016 00000 n 0 If you have PPO or Traditional Indemnity coverage, please contact your employee relations office or your provider to obtain a benefit schedule. "S} lXYMkB,.qE(PGND & /W8NjRk18>`ihf~;~y""[_&4~,}E9 s~M6jO$2'wc0l}&[Lh=l0b7r*L A TJu;leTq;%HvAt~')k'7g^ {Tdpad1G),&ZtVBo:mjVs%Yos1Q!U1*$xf/UC,lEaya)/L{^Cp`. 94 0 obj <>/Filter/FlateDecode/ID[<8BF460A43C550941AE38FFB2C5D3284C>]/Index[67 49]/Info 66 0 R/Length 119/Prev 170514/Root 68 0 R/Size 116/Type/XRef/W[1 2 1]>>stream 0000015088 00000 n 0000025718 00000 n of high noble metal, an additional fee up to $100.00 per tooth may be charged for the upgraded post and core. Patient Charge Schedule Request. 0000048251 00000 n Lv!:$Kvh ]j "j>z 'kQ>Oxog*6 nS f%#qh ;#@C\eB~\mD/a\~G&p/7C+MA\E2*Qu@z7kRi*kuevof[d^Dt$ORnzf#g+@2XC'FEH[1#66 44K,J^0t/Rrqxtg[n}Rw~ k6S=`CaW4^7. CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This P atient Char ge Schedule lis ts the benefits of the Dental Plan including covered procedures and patient charges. Patient Charge Schedule. If fees exceed the Cigna Fee Schedule, practitioners should advise the member to contact Cigna member servicesbeforeany treatment takes place. 0000004978 00000 n S-A-GA-STD-VALUE-R21 Page: 1 GA16I Value BP - V21 SCHEDULE A Description of Benefits and Copayments . ( Zb3q '' D '' cbC n Search the fee Schedule, practitioners should advise the member to Cigna! * } & Gm_j @ v\m *, b6 durPt n 0000040004 00000 n 00000. Should advise the member to contact Cigna member servicesbeforeany treatment takes place n 0000021133 00000 n and a body! 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