Understanding dental benefits on the Standard Care Plan

During our year-end presentations members asked us to provide them with information about the dental benefits on the Standard Care Plan and how the network arrangement with the Dental Risk Company (DRC) works. 78% of member visits for basic or day-to-day dentsi try are currently taking place at a contracted DRC network provider.

Accessing available benefits

Standard Care Plan members have access to a basic dental services benefit, provided by the DRC, as well as an additional basic and specialised dentistry family limit of R1 390 per adult and R345 per child.

The purpose of the network arrangement with the DRC is to cover a member’s dental maintenance and preventative care from risk and still provide a limited benefit for advanced dentistry procedures. This is achieved through the DRC list of contracted network providers. There are normally two or three providers to choose from in a given area.

AMS encourages members to take advantage of the benefit which, if used correctly, should provide the entire family with basic dental care for the year with minimal or no co-payments. To access the benefit, a member must preferably visit a contracted DRC network provider for claims to be paid at 100% of the Scheme Reimbursement Rate. Members, however, still have a choice of visiting any provider, but AMS will then only pay the claims at 80% of the Scheme Reimbursement Rate.

The best prevention: make regular use of basic dentistry

As basic dentistry is the most important form of dental maintenance and preventative care, the following benefit package, if used properly, will ensure that your teeth remain healthy for the full 365 days of a benefit year:

• Consultations – full mouth examinations managed to ensure 2 visits a year (180 days apart from each other), and specific condition visits. It is only necessary to have a full mouth examination every 180 days as the network provider will formulate a treatment plan to address all your issues found during this examination.
• General hygiene and preventative care – scaling, polishing, and fluoride treatment every 180 days, infection control and sterilisation covered once per visit.
• Diagnostic cover and anaesthetic – intra-oral radiographs at 2 films per visit and local anaesthetic 1 per visit are covered.
• Extractions – 1 local anaesthetic per visit are covered and providers must pre-authorise more than 4 extractions.
• Restorations – all amalgam and resin restorations are covered, but the provider must obtain authorisation from the 5th restoration for the year.
• Dentures – plastic dentures every 4 years with cover for repairs and relining annually.

Additional basic and specialised dentistry benefit

Should you need additional dental work before the 180 days are up, the claims will be paid from your additional basic and specialised dentistry benefit. In this case, your next preventative consultation would need to be 180 days after the last consult.

The following advanced dentistry procedures will be covered from your family dental limit:

• Root canal treatment
• Orthodontic treatment
• Crowns or bridges
• Periodontic treatment
• Maxilla facial treatment
• Implants
• Any other service not covered in the basic dental maintenance and preventative care package.

Why is a network beneficial?

Network providers have signed a Memorandum of Understanding (MOU) with the DRC and agreed to the following:

• To submit claims to the Scheme for processing and not charge the member upfront for covered procedures.
• To claim according to the Scheme Reimbursement Rate for covered codes.
• To be aware of the Plan’s benefit and advise members of what is not covered prior to performing the procedure.
• To facilitate pre-authorisation processes and submit these to the DRC. Upon receipt of a response they need to advise the member of what is covered and what is not covered in accordance with the authorisation document they receive back from the DRC.
• To adhere, wherever possible, to the DRC protocols as provided to them via the DRC provider operational manual, which is distributed annually to ensure that providers are kept abreast of changes to benefits and processes.
• Your contracted network provider has received a manual from the DRC explaining all authorisation and protocol requirements. The DRC aims to ensure that all claims are paid efficiently and correctly. Should you have any questions or queries, please call the AMS Call Centre on 0860 222 633