What’s Not Covered

Avoid Claim Delays

To ensure that your claims are processed quickly and accurately, answer all questions on the form. Ask your provider to complete the appropriate sections, such as:

• the date care is received,
• the patient’s name, address, and ID number,
• the provider’s name, address, and taxpayer ID number,
• the procedures performed and the supplies furnished, and
• the amount charged for each procedure or supply.

The MPTN Dental Plan does not cover the following treatments and services:

• Dental services received from a dental or medical department on behalf of an employer (other than MPTN), mutual benefit association, labor union, trustee or similar person or group.
• Dental services for which you incur no charge.
• Dental services for which coverage is available, in whole or in part, under any Workers’ Compensation Law or similar legislation, whether or not you claim compensation or receive benefits under that law, and whether or not any recovery is had by you against a third party for damages resulting from a condition, disease, ailment or accidental injury necessitating dental services.
• Dental services with respect to some congenital malformations or primarily for cosmetic or esthetic purposes (i.e., replacement of congenitally missing teeth or retained deciduous teeth).
• Dental services furnished or available in whole or in part under the laws of the United States, or any state or political subdivision thereof, or for which you would have no legal obligation to pay in the absence of this or any similar coverage.
• Appliances or restorations necessary to correct bite problems or restore the occlusion or correct temporomandibular joint dysfunction (TMJ), with the exception of a night guard (bruxing appliance).
• Dental services to replace tooth structure lost due to abrasion or attrition.
• Services rendered by a dentist beyond the scope of his or her license.
• Dental services to the extent that charges for the services are greater than the charge that would have been made and actually collected if no dental coverage existed.
• Dental care or treatment not specifically listed as a covered expense.
• Dental services resulting from loss or theft of a denture, crown or bridge.
• Provisional splinting.
• Courses of treatment which were undertaken before the person became covered under this plan.
• Any services performed after the last day of the month during which any person ceases to be eligible for coverage under this plan.
• Services for, or related to, the instruction for oral hygiene or plaque control.
• Dental services which do not have uniform professional endorsement as a covered dental expense.
• Cosmetic dentistry.
• Services not medically necessary or not at the most appropriate level of care.
• Restorative, endodontic, or prosthetic services performed on teeth with moderate to severe periodontal involvement.
• Temporary services.