Dental Plan – Breakdown For Providers

 ATTENTION NEW PROVIDERS:

W9 forms must be on file prior to payments being issued.

You can avoid payments being delayed by faxing your W9 form to (918) 280-4899


MAIL OR FAX PAPER CLAIMS TO:

PIBF DENTAL PLAN
P.O. BOX 470950
TULSA, OKLAHOMA 74147-0950

CLAIMS FAX: (918) 280-4899


 PPO: Dental Network of America > www.dnoa.com
*Careington PPO
*Dentemax PPO


100% / No Deductible
Periodic Exam – every 6 mos.
Prophy – every 6 mos.


All Other Covered Services:
$100 DEDUCTIBLE PER PERSON PER CALENDAR YEAR
$1,000.00 MAXIMUM PER PERSON PER CALENDAR YEAR
EFFECTIVE 1/01/11 > NO YEARLY MAXIMUM FOR CHILDREN 18 AND UNDER
PAYABLE AT 80% IN-NETWORK / 70% OUT-OF-NETWORK

  • DIAGNOSTIC
  • DENTURE REPAIRS
  • PREVENTIVE
  • DENTURES & PARTIALS
  • EXTRACTIONS
  • CROWNS
  • FILLINGS
  • ENDODONTICS
  • PALLIATIVE
  • ORAL SURGERY
  • GENERAL ANESTHESIA (All anesthesia is covered)
  • PERIODONTIA
  • OCCLUSAL GUARD (For Bruxism Only)

Other Services NOT Covered:

  • ORTHODONTIC TREATMENT
  • DENTAL IMPLANTS
  • TEMPORARIES AND TMJ

There are no frequency limits
There is no missing tooth clause
There is no waiting period
There is no age limit for Fluoride treatment
There is no tooth limit for Sealant treatment
Posterior Composites are not down graded


SERVICES BEING DONE IN OP FACILITY:
A Letter of Medical Necessity stating why the dental services are being performed in an OP facility must be sent to PIBF for review and approval/denial
prior to services being performed


BENEFITS ARE DETERMINED ONCE THE CLAIM IS RECEIVED FOR PROCESSING


For a PDF version of this document click HERE.


 

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