Dental Preferred Provider Organization (PPO) FAQs | Aetna

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Dental Preferred Provider Organization (PPO) FAQs

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  • General/administration questions

  • Network questions

  • Plan design

General/administration questions

Aetna Dental members do not need a thành viên ID card to get dental care. When you go to the dentist, tell the office staff that you have Aetna Dental and they will verify your coverage .

You can view and print your ID card from your thành viên website. Signing up is simple and không lấy phí .

Register and log in today

You can also view and share your digital ID card from the Aetna HealthSM app. Download this không tính tiền app today at the App Store or Google Play .

Learn more about the Aetna Health app

If your plan has a coordination of benefits provision, we confirm which plan has primary responsibility for claim payment. If we have primary responsibility, we pay as the primary payor. If not, we pay as the secondary payor .

The primary payor pays claims as it normally would, as if there were no secondary payor. The secondary plan acts like a supplement to the primary plan .

If you are enrolled in two dental plans, and each plan covers two cleanings per year, you are not entitled to four cleanings per year .

Please note that there are several types of coordination of benefits provisions. They may differ by plan. If you need more information, please contact Member Services using the number on your ID card .

No .

Network questions

You can find a network dentist using our trực tuyến directory. For personalized results, first log in to your secure thành viên website. Search for a dentist by name, specialty, zip code or the number of miles you are willing to travel .

Log in to find a dentist who accepts your coverage

Find a dentist using our public site

Network Dentists

Network dentists have agreed to offer certain services at a negotiated rate. If you visit a network dentist, you generally pay less out of pocket .

  • If your plan has a deductible (a dollar amount you must pay for covered expenses in a plan year), you must meet the deductible before your plan covers your eligible dental expenses. 
  • After you meet your deductible, you will pay a coinsurance amount (a percentage of covered expenses) at the time of service. See your plan documents to learn this amount. 
  • Your dentist may submit your claims for you.
     

Out-of-network dentists

Dentists who are not in our network may bill you their normal fee for procedures. Your plan provides benefits using amounts that we have set as the ” recognized charge ” for each service in your geographic area. When we set the ” recognized charge ” we may consider other factors, including the prevailing charge in other areas. The amount of our ” recognized charge ” does not suggest your dentist’s fee is not reasonable and proper .

Your dentist may bill you for the difference between his or her normal fee and our ” recognized charge. ” This amount is not covered, and you must pay it .

  • Your plan may have a deductible. The deductible is the dollar amount you must pay before your plan covers your eligible dental expenses.
  • You may pay a coinsurance percentage or flat dollar amount. That means you’ll pay a portion of covered expenses at the time of service. See your plan documents for specific amounts.
  • You or your dentist can submit a claim form for reimbursement.

If you are enrolled in a PPO Max plan, your out-of-network benefits will be based on the standard rates for network dentists in that geographic area. Please see your plan document or contact Member Services for details .

Plan design

Your Aetna Summary of Benefits describes the services that are covered under your plan. You can get a Summary of Benefits from the employer that is providing your insurance .

Yes, but some plans may limit the benefit to certain teeth. Contact Member Services if you have questions .

If the teeth were lost or extracted before your coverage began, then services to replace them may not be covered by your plan. This applies to first-time dentures, fixed or removable bridges, and implants. For more details, contact Member Services or review your plan documents .

Please see your plan documents or contact Member Services for coverage details .

Yes. Some services have this type of restriction. Please see your plan documents or contact Member Services for details .

See our Orthodontia FAQs

If you were covered under a previous insurance carrier, certain services will be covered by that plan even after your Aetna coverage begins. This is called an extension of benefits provision. Thes e services include :

  • Crowns and fixed bridgework, when the teeth were prepared before your Aetna coverage began 
  • Appliances (such as dentures), when the impression was taken before your Aetna coverage began
  • Root canal therapy, when the tooth’s pulp chamber was opened before your Aetna coverage began

If you had no coverage when you started treatment for a service, that service may not be covered under your Aetna plan. Contact Member Services to see if your plan has a work-in-progress exclusion.

If more than one service is needed to fix a problem, most services are considered separately .

Have your dentist send a request for a pretreatment estimate ( predetermination ) to us. This will let you and the dentist know what the benefit would be if the service were done. You or your dentist may also call Member Services at the number on your ID card .

See our FAQs about oral surgery

Periodontal maintenance is for patients who have previously been treated for periodontal disease .

Texas Members: In Texas, the Preferred Provider Organization (PPO) plan is known as the Participating Dental Network (PDN).

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The Applied Behavior Analysis ( ABA ) Medical Necessity Guide helps determine appropriate ( medically necessary ) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider .
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply .
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered ( i. e., will be paid for by Aetna ) for a particular thành viên. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary .
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change .
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the sự kiện that a thành viên disagrees with a coverage determination, thành viên may be eligible for the right to an internal appeal and / or an independent external appeal in accordance with applicable federal or state law .

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