Guidelines

Claim Forms: Must be fully completed.

Date of Service: Must reflect date the crown or prosthetic is seated, as benefit eligibility is based on seat/delivery for crowns and prosthetics.

Fillings: Pre-op x-rays are required if the treatment plan includes multiple anterior restorations or six or more posterior teeth.

Crowns/Onlays: Treatment plans including two or more crowns and/or onlays require submission of current, diagnostic-quality pre-op x-rays.

Tissue Grafts: Treatment plans involving three or more teeth require pre-op photographs in addition to current periodontal charting and/or a narrative detailing existing conditions; specifically, the amount of remaining, attached keratinized tissue and other contributing factors.

Additional Periodontic Procedures: Current (pre-op) full-mouth, six-point periodontal charting (including mobility) should be submitted. Additionally, a four week wait is required between root planing and osseous surgery. Resubmit new charting following root planing and prior to completing osseous surgery.

Initial Orthodontic Procedures: Submit start date, proposed treatment months, total charges and brief narrative of treatment or function of appliance. Orthodontic claims must be submitted to SDC within three months of treatment initiation.

Orthodontic Procedures in Progress (at the time SDC eligibility is established): Initial cost, start date and initial estimate of months of treatment. Orthodontic claims for work in progress must be submitted to SDC within three months of member’s SDC eligibility.

X-Rays or Other Documentation: May be requested at the discretion of SDC’s Dental Consultants to complete review of a submitted service. If requested, please send diagnostic-quality copies of x-rays.