Dental Insurance

Dental Care Exclusions and Limitations

• Services totalling $500 or more must have prior approval from GMS before the services are begun.If a dental pre-authorization is not submitted prior to commencement of services, benefits otherwise payable shall be limited to $500 for the services performed.
• GMS will pay for services and procedures only to the maximum amounts as provided for in the Dental Fee Guide. Any charges over and above the Dental Fee Guide will be your responsibility.
• GMS will only cover standard cast chrome with external clasp retainers or acrylic partial denture. When an alternate appliance is supplied, GMS will pay the standard rates.
• If you and the dentist decide on a personalized restoration in the construction of a denture, or specialized techniques are employed as opposed to standard procedures, GMS will provide benefits at the appropriate amount for a standard denture and standard techniques.
• GMS will pay only for x-rays performed by a dentist.
• The provision of prosthetic devices including complete dentures, partial dentures, fixed bridgework(and crowns that are part of the bridgework) shall not be covered under this policy if the device was ordered or the service for the device was started before the benefit effective date.
• The policy covers only necessary and adequate dental services.Where there is a dispute as to necessary and adequate dental services., the determination of GMS shall be final.
• Where an examination has been performed that identifies necessary and adequate dental services, GMS will pay for the examination fee and the necessary and adequate dental services.as covered under the policy.Fees for secondary dental examinations during the treatment of the dianosed dental services will not be covered.
• Multiple restorations submitted on the same tooth will be limited according to reasonable and customary charges as indicated in the Dental Fee Guide.
• Waiting Periods.
  a. The benefit effective date for Dental Care Benefits coverage occurs after being enrolled in this option for three(3) months.
  b. In situations where a person is changing from another GMS Plan, waiting periods will be waived for any Dental Care Benefits which were covered under the previous GMS Plan, if the person was enrolled in that plan for atleast (3) months.The waiting period will not be waived if the previous GMS plan provided coverage only for accidental injury to natural teeth.
  c. In situations where a person is transferring from another insurance carrier, waiting periods will be waived for comparable dental care benefits which were covered under the previous carrier's plan, if the person was enrolled in that plan for at least three(3) monthsProff of previous coverage is required in order to have benefit waiting periods waived.
• The following services or supplies are excluded from coverage:
  a. expenses compensable under Worker's Compensation Laws or any Government Agency.
  b. expenses for cosmetic purposes.
  c. expenses associated with congential defects, developmental malformations or temporomandibular joint disorders.
  d. expenses for implants or crowns involved in an implant procedure and surgical insertion.
  e.expenses for the replacement of lost or stolen dentures.
  f. expenses incurred to increase vertical dimension and repair or restore teeth damaged or worn due to attrition or vertical wear.
  g. expenses for tissue grafts.