Select Plan 703X
A. Enrollment and Eligibility
You and your dependents are eligible. Dependents include your spouse and unmarried children up to age 26.
B. Your Effective Date
If your application and payment are received by the 25th of the month, your plan will be effective on the first day of the following month.
C. How do I receive care?
After your effective date, simply call the dental office you selected, make an appointment and present your membership card upon arrival. There are no claim forms or waiting periods. You simply pay any fee amounts listed to your selected dental office at the time of service.
D. Annual Deductible & Calendar Year Maximums
There are no annual deductibles or calendar year maximums.
E. Choice of Provider
You may choose any of the conveniently located dental offices from the list of participating dentists. Each family member may select a different participating dentist.
F. Specialty Care/Specialist Referrals
Specialty care is covered on this plan. The fees apply only when services are performed by your selected general dentist. Plan Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists.
G. Emergency Dental Services
You are covered up to $100 for palliative emergency dental treatment arising from accidental injury or illness while temporarily more than 50 miles from your home. Simply use any convenient dentist and submit the receipt to Dominion for reimbursement. The $100 limit does not apply in Pennsylvania.
H. Coordination of Benefits
This plan may be coordinated with additional dental coverage you may have. This coverage can only be coordinated as the primary program.
I. Termination or Cancellation
Benefits shall cease upon the earliest of the following events:
- On the date of expiration of the period for which the last payment of Monthly Membership Fees was made to Plan. In the event that subscriber wishes to continue coverage for an additional year, a grace period of 31 days from the due date shall be granted for payment.
- Upon date of dependents attaining the age of 26 years, benefits to such dependents shall cease.
- If after reasonable efforts to establish and maintain a satisfactory dentist-patient relationship, the Participating Dentist is unable to do so, the Plan reserves the right to transfer the Subscriber and Dependents to a second and third Participating Dentist of their choice. If the third Participating Dentist is also unable to establish a satisfactory dentist-patient relationship, the Plan reserves the right to terminate the membership of said Subscriber and Dependents.
- Upon violation of the terms of the contract, fraud or deception in the use of services, under which the Member is covered.
- Services which are covered under Medicare, worker’s compensation, employer’s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only).
- Services which, in the opinion of the attending dentist, are not necessary for the patient’s dental health.
- Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth.
- Oral surgery requiring the setting of fractures or dislocations.
- Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the opinion of the Participating Dentist, such services should not be performed in a dental office.
- Dispensing of drugs.
- Hospitalization for any dental procedure.
- Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.
- Replacement due to loss or theft of prosthetic appliance.
- Procedures not listed as covered benefits under this Plan.
- Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or Dominion National, Inc. (with the exception of out-of-area emergency dental services).
- Services related to the treatment of TMD (Temporomandibular Disorder).
- Services related to procedures that are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Participating Specialist (with the exception of orthodontics). Participating Specialists, if available, have entered into an agreement with Dominion National to provide dental services to members at a 25% reduction from their Usual, Customary, and Reasonable (UCR) fees. In Delaware, Participating Specialists will provide a reduction from their UCR that will vary between specialists.
- Elective surgery including, but not limited to, extraction of nonpathologic, asymptomatic impacted teeth.
- The Invisalign system and similar specialized braces are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility.
- Two (2) evaluations are covered per calendar year including a maximum of one (1) comprehensive evaluation.
- One (1) emergency or problem focused exam is covered per calendar year.
- Two (2) teeth cleanings (prophylaxis) are covered per calendar year (one additional cleaning is covered during pregnancy and for diabetic patients).
- One (1) topical fluoride or fluoride varnish is covered per calendar year.
- Two (2) bitewing x-rays are covered per calendar year.
- One (1) set of full mouth x-rays or panoramic film is covered every three (3) years.
- One (1) sealant or preventative resin restoration per tooth is covered per lifetime, up to age 16 (limited to permanent 1st and 2nd molars).
- Replacement of a filling is covered if it is more than two (2) years from the date of original placement.
- Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement.
- Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.
- Relining and rebasing of dentures is covered once every 24 months.
- Retreatment of root canal is covered if it is more than two (2) years from the original treatment.
- Root planing or scaling is covered once every 24 months per quadrant.
- Full mouth debridement is covered once per lifetime.
- Procedure Code D4381 is limited to one (1) benefit per tooth for three teeth per quadrant or a total of 12 teeth for all four quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater.
- Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgical site.
- Periodontal maintenance after active therapy is covered twice per calendar year, within 24 months after definitive periodontal therapy.
K. Greivance Procedures
Complaints should be initially brought to the attention of the Member’s Participating Dentist. If the issue is not resolved to the Member’s satisfaction, it may be sent in writing to the Director of Member Services, Dominion National, 115 South Union Street, Suite 300, Alexandria, Virginia 22314.