CCTBF Dental Plan
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Plan Summary
Services In-Network Out-of-Network
Preventive Services* 100% MAC* 80%
Emergency Palliative Treatment
Oral Examination 3 per policy year
X-rays bitewings full mouth series every 3 years
Bitewings – no more than 8 films per policy year
Teeth Cleaning – 3 per policy year
Fluoride Treatments for Children
(2 per policy year to age 19)
Topical Sealants for unrestored molar teeth covered
Basic Services 90% MAC* 80%
Laboratory Test
Fillings: Amalgam, Silicate & Acrylic
Crowns: Stainless Steel
Repairs of dentures, bridgework, crowns, etc.
Endodontic Services/Root Canal Therapy
Periodontal Services
Oral Services – Uncomplicated extractions
General Anesthesia – surgical procedures only
Injectable Antibiotics – for treatment of a dental
condition only.
Major Services 80% MAC* 80%
Bridges Installation-fixed and removable
Dentures-Full and Partial Crowns: Acrylic, Metal, Porcelain
Inlays
Onlays
Posts
Implants
*MAC: Maximum Allowable Charge is equivalent to the amount paid to in-network providers.
Orthodontic Services 80% MAC* 80%
$3,000 Individual Lifetime Maximum and $5,000 Combined Family Lifetime Maximum.
(As of July 1, 2017, the amount paid for pediatric orthodontia is NOT included in your plan year maximum.)
New member per person maximum is $750 during the first year of eligibility.
The plan year runs from July 1 to June 30.
Employee/Dependents enrolling outside of the plan eligibility period may be subject to the first year $750 per person maximum.
Children are covered up to age 19, or up until age 26 if an eligible full time student with proof of full time college enrollment.
All out of network services are based on Maximum Allowable Charge (MAC) which is equivalent to the amount paid to in-network providers.
Predetermination Review – For services and procedures of $750 or more, we encourage your dentist to submit a predetermination of benefits to ASO before treatment begins. ASO will advise you and your dentist of the approved covered procedures. A predetermination is optional and is not a condition of coverage — no claim is denied for lack of one. (This includes orthodontic treatment.)
Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan.
General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: cosmetic or experimental treatments, any treatments to the extent benefits are payable by any other payor or for which no charge is made.
HOW TO FIND A DENTAL PROVIDER:
To find a participating dentist, visit asonet.com and sign in to your member account. Under Quick Links, select "Find a Dentist." You may also visit www.cctbf.com and navigate to Benefits Booklet > Dental Summary > Anthem Network.
To locate a provider, please reference our on-line Provider Directory at:
● https://www.cctbf.com/dental-plan (or go to www.cctbf.com and select Dental from top navigation bar)
● Click on “Aetna Dental” or “Anthem Network” (Here are explicit instructions to search the Anthem network)
● Answer prompt for type of provider (dentist, periodontist, etc..) See types of providers listed.
● Type in zip code
● When prompted to select your plan, select: “AccessSM/AetnaDental Administrators”
DENTAL CLAIMS WHEN SHOULD YOU SUBMIT A CLAIM?
When you have a claim, you should promptly submit the completed claim form and any bills or receipts.
Claim forms must be fully completed by all parties (provider and member) and filed within 90 days from the close of the plan year.
The plan year is July 1 – June 30.
Please note: Benefit checks may have an expiration date. Please cash promptly.
HOW TO FILE YOUR DENTAL CLAIM FORMS:
Complete the entire Employee portion of the Claim Form.
If the Claim is for yourself, your coverage is the primary plan.
If the claim is for your spouse and he/she has other coverage, be sure to attach the CHAPPAQUA CONGRESS OF TEACHERS BENEFIT FUND Explanation of Benefits (EOB) or declination from his/her plan.
If the claim is for your dependent children and your birthday (month and day) is earlier in the calendar year than your spouse's, you should file first. If your spouse's birthday is earlier, you must file with your spouse's plan first, and attach copies of his/her EOB to the claim you are filing through our plan.
Attach provider’s itemized bill(s) or have the provider complete his or her portion of the form.
American Dental Association Dental Claim Form
WHERE TO FIND YOUR DENTAL CLAIM FORMS:
Dental Claims Forms can be found at: https://www.cctbf.com/forms or by visiting the CCTBF website at www.cctbf.com.
Please submit Dental Claim Form to ASO.
For details/questions, contact:
Chappaqua Congress of Teachers Benefit Fund
c/o Administrative Services Only, Inc. (ASO)
P.O. Box 9005, Dept 270
Lynbrook, NY 11563
Member Services: 800-537-1238
Web: asonet.com
Questions and claims are handled through your member account at asonet.com.
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