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975 East Third Street
Chattanooga, TN 37403
423-778-7000
Children's Hospital at Erlanger Erlanger Baroness Campus Erlanger Bledsoe Campus Erlanger East Campus Erlanger North Campus UT Erlanger Physicians Group





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Dental Care Plan

Erlanger Health System offers an Individual and Family Dental Plan. The Dental Plan covers preventive, basic, and major services. Under the plan you may visit any licensed dentist. The dental insurance premiums are deducted from an employee’s paycheck on a pre-taxed basis. BlueCross BlueShield of Tennessee provides the current dental insurance plan.

Eligibility
To be eligible for Dental Insurance Coverage, an employee must be classified as a regular employee and at least a .52 FTE or greater. An employee may elect individual or family coverage.

Enrollment 
Eligible employees may enroll in individual or family dental insurance coverage within 31 days of hire or within 31 days of a change in status. Events that cause a change in status includes, but not limited to marriage, divorce or the birth of a child. Eligible employees may also enroll for coverage during the Open Enrollment Period.

Effective Date of Coverage 
New Hires
The Effective Date of Coverage will be the first of the month following the initial one-month waiting period.
Status Changes
The Effective Date of Coverage for status changes will be the date of the change. For example, if a PRN employee transfers to a .52 or greater FTE position, coverage is effective on the date of transfer, if the initial one-month waiting period has been met.

How to File a Claim – Participating Dentist
Simply present your dental card when dental work is performed by a participating Dentist. The participating Dentist will file the claim for you. Payments will be made directly to the participating Dentist.

How to File a Claim – Non-Participating DentistI
f you select a Dentist who is not participating in the Preferred Dental Care Plan, that Dentist can bill you for any amount not covered by the Dental EOC.
If you select a non-participating Dentist, you must file the claim yourself. “Attending Dentist’s Statements” for a non-participating Dentist are available through Human Resources.

Dental Plan Premiums

Employee Status Premium/Month Premium/Pay Period
Individual 10 5
Family 37.50 17.50


 

Dental Plan Schedule of Benefits

NOTE: Please note that this is a Summary of Benefits. Changes may be made at any time. Please refer to your BlueCross BlueShield of Tennessee Evidence of Coverage book or contact BlueCross BlueShield for specific coverage questions.

Coverage

  Deductible Co-Insurance Benefit Period Max
A $0 100% Benefit Period Maximum
$1,000 Calendar Year Maximum
Ortho Lifetime Maximum:
$1,500 Lifetime Maximum
B $25 90%
C $25 70%
D $0 50%

Coverage A - Basic Preventive Services
• Routine periodic examinations up to 2 in any 12-month period, including 2 bitewing x-rays in any 12-month period.
• Full-mouth x-rays once in any 36-month period.
• Topical fluoride application for dependent children under 19 once in any 12- month period
• Prophylaxis, including cleaning, scaling, and polishing twice in a 12-month period.

Coverage B – Restorative Services and Oral Surgery
• Emergency treatment for relief of pain.
• Restorative services: filling material such as amalgam, synthetic porcelain, and plastic restorations.
• Oral Surgery: provides for extractions and other oral surgery.
• Endodontics, including pulpotomy, pulp capping, and root canal treatment.
• Peridontics (treatment for diseases of the gums).
• Repair of full and partial dentures.
• Space maintainers for dependents up to age 14.
• Temporary stainless steel crowns.
• Sealants on occlusal surface of first and second permanent molars for dependents up to age 16, one tooth per member.

Coverage C – Crown and Prosthetic Care
• Cast crowns (plastic, plastic with non-precious metal, porcelain with non-precious metal) for age 12 and older.
• Bridges, construction, placement, and repair of bridges and full and partial dentures for dependents over age 16.
• Relining of full and partial dentures, one in a 3-year period.
• Benefits will be provided for crowns, fixed bridges and prosthetic appliances once in any single 5-year period.

Coverage D – Orthodontic Care
• Straightening and alignment of teeth for dependent children under 24 years of age or to age 25 if full-time student

How to Contact BlueCross BlueShield of Tennessee
You may contact BlueCross BlueShield of Tennessee by telephone at 1-800-565-9140 or through their website at www.bcbst.com. Please have your dental insurance card ready with account information.