Blue Cross Blue Shield FEP Dental Brochure - 2022

Blue Cross Blue Shield FEP Dental
Section 3 How You Obtain Care
Alternate Benefit
In some cases, you and your dental practitioner have a choice of treatment options and if more than one service can be used to treat your dental condition, we may decide to only authorize alternate treatment for a less costly covered service if the service selected is an appropriate method of treatment. This benefit application is done in an effort to keep your dental premiums affordable and assure you have coverage for the most common types of dental treatment. The dental plan limits benefits to the maximum allowable charge for the least costly covered service that accomplishes a result that meets accepted standards of professional dental care as determined by us. We will limit benefits payable to the benefit that would have been payable if the least costly covered service had been provided. This is called the alternate benefit.

If you and your dentist choose the more expensive treatment instead of the alternate benefit, you are responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider provides services. This means that any difference between the alternate benefit and the charge actually incurred is your responsibility, including any applicable coinsurance.

BCBS FEP Dental recommends receiving a pre-certification/pre-determination prior to receiving services so you and your dental provider are aware of the coverage terms and benefits. For example, if the dental consultants determine an arch can be restored with a standard prosthesis or restoration, no benefits will be allowed for the individual implant or implant procedures. An implant is a covered procedure of the plan only if determined to be dentally necessary and least expensive appropriate treatment. We will review the clinical documentation submitted by your treating dentist. If the Dental Advisor determines the implant is not dentally necessary or a less expensive appropriate treatment is available no benefits will be allowed for the individual implant or implant procedures, and the allowance for the less expensive treatment may be approved. For example, full mouth reconstruction is not a covered benefit.