Dental PPO

Information on using the Dental PPO

Q1. Are my out-of-pocket costs different if I use a network dentist versus a non-network dentist?

A1. When you use a network dentist, you save money because these participating providers have agreed to provide their services at negotiated rates that are generally less than the rates charged by non-network dentists.

Q2. Are my benefits different if I use a network dentist versus a non-network dentist?

A2. The percent of eligible charges that the Plan pays is the same whether you use network or non-network providers. However, you may be responsible for charges above the reasonable and customary (R&C) limit for non-network providers (see Reasonable and customary limits under Adjustments and Billed Charges in the Payments section).

Using the Dental PPO

Using the Dental PPO is completely voluntary. The Dental PPO provides access to a network of dentists and dental specialists who have met Aetna's standards for licensing, academics and service. Dental PPO providers' charges are always within reasonable and customary limits. (See Reasonable and customary limits under Adjustments and Billed Charges in the Payments section.)

There are several advantages to using network providers:

  • The discounts offered by network dentists generally lower your out-of-pocket costs and allow you to cover more dental services for the annual benefit maximum.
  • Network dentists submit claims for you, so you do not have to complete claim forms.
  • Negotiated rates are within reasonable and customary limits, so you will not have to pay charges above the limits. However, the alternative course of treatment rules noted in the Adjustments to Billed Charges section apply.

To receive the benefit of negotiated rates, use network dentists and present your Aetna Dental PPO ID card.

To find a dental PPO provider:

  • Check DocFind® www.aetna.com/docfind on Aetna's Web site for the most up-to-date list of dental PPO providers. The site is updated three times a week.
  • Call Aetna Member Services for help with locating a PPO provider or to request a printed listing of providers.

Confirm with Aetna Member Services and/or the dentist's office whether the dentist participates in the network before the appointment, since network participation may change.

If you or your covered family members need to see a dentist while away from home, you can go to any licensed dentist. However, you may access the Aetna Web site or contact Aetna Member Services to see if there is a network dentist in the area.

Pre-determination of benefits

You are encouraged to submit a pre-determination of benefits before you begin any complicated or expensive dental procedure to avoid unexpected expenses.

Generally, Aetna will tell you what benefits will be paid for the proposed treatment. However, if a less expensive alternative course of treatment is available, Aetna will advise you of the alternative course of treatment and tell you what benefits will be paid. If you decide to have the more expensive proposed treatment, the Plan pays benefits based on the cost of the alternative course of treatment.

Here is how the pre-determination process works:

  • Indicate on a claim form (or in a letter) that you are seeking a pre-determination of benefits. Give the form to your dentist.
  • The dentist describes the suggested course of treatment, itemizing specific services and charges. In some cases medical information, including x-rays, may also be needed.
  • The dentist submits the information to Aetna, which determines the Plan benefits for the services outlined and notifies both you and the dentist. This gives you a chance to discuss the work and charges with your dentist before the work is performed.

If a lower cost alternative course of treatment would be medically appropriate, you might decide to proceed with the original treatment, or you might opt for the alternative course of treatment. That is a matter for you and your dentist to decide. Plan benefits are based on the actual work done or on the Plan's requirements relating to alternative course of treatment, not on the pre-determination. (See Alternative course of treatment under Annual Maximum in the Payments section).

Note: A pre-determination is processed much like a claim. Plan accordingly and allow sufficient time for that process to take place.