2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(g). Dental Benefits
Accidental Injury Benefit
Section 5. Benefits
Section 5(g). Dental Benefits
Accidental Injury Benefit
Benefit Description
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
Note: A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.
Basic Option - You Pay
$30 copayment for associated oral evaluations
30% of the Plan allowance for all other care
Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share amounts as shown above. If you use a non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
Note: A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.
Basic Option - You Pay
$30 copayment for associated oral evaluations
30% of the Plan allowance for all other care
Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share amounts as shown above. If you use a non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.