Guidelines

Claim Forms: Must be fully completed.

Crowns, Prosthetics and Onlays: The date of service must reflect the seat/delivery date, as benefit eligibility is based on when the restoration is seated. Treatment plans including two or more crowns and/or onlays require current, diagnostic-quality pre-op x-rays.

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

Tissue Grafts (SDC only): 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 attached keratinized tissue remaining and other contributing factors.

Periodontic Procedures (SDC only): 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. For SDC members, orthodontic claims must be submitted within three months of treatment initiation.

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

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

Missing Tooth Clause: SDC and Medical Mutual plans do not have a missing tooth exclusion. Our plans cover tooth replacement procedures for members who had a tooth fall out or extracted prior to enrollment.