Using the Dental PPO is completely voluntary. The Dental PPO provides access to a network of dentists and dental specialists who have met Aetna's standards for licensing, academics, and service. Dental PPO providers' charges are generally within reasonable and customary limits. (See Reasonable and customary limits under Adjustments to Billed Charges in the Payments section.)
There are several advantages to using network providers:
- The negotiated rates offered by network dentists generally lower your out-of-pocket costs and allow you to cover more dental services for the annual benefit maximum.
- Network dentists submit claims for you, so you do not have to complete claim forms.
- Negotiated rates are within reasonable and customary limits, so you will not have to pay charges above the limits. However, the alternative course of treatment rules noted in the Adjustments to Billed Charges section apply.
To receive the benefit of negotiated rates, use network dentists and present your Aetna Dental PPO ID card or member identification number.
To find a dental PPO provider:
- Check the Aetna Provider Directory on www.aetna.com for the most up-to-date list of dental PPO providers.
- Call Aetna Member Services for help with locating a PPO provider.
Confirm with Aetna Member Services and/or the dentist's office whether the dentist participates in the network before the appointment, since network participation may change.
If you or your covered family members need to see a dentist while away from home, you can go to any licensed dentist. However, you may access the Aetna website or contact Aetna Member Services to see if there is a network dentist in the area.
Pre-determination of benefits
You are encouraged to submit a pre-determination of benefits before you begin any complicated or expensive dental procedure to avoid unexpected expenses.
Generally, Aetna will tell you what benefits will be paid for the proposed treatment. However, if a less expensive alternative course of treatment is available, Aetna will advise you of the alternative course of treatment and tell you what benefits will be paid. If you decide to have the more expensive proposed treatment, the Plan pays benefits based on the cost of the alternative course of treatment.
Here is how the pre-determination process works:
- Ask your dentist to submit a pre-determination of benefit request.
- The dentist describes the suggested course of treatment, itemizing specific services and charges. In some cases medical information, including x-rays, may also be needed.
- The dentist submits the information to Aetna, which determines the Plan benefits for the services outlined and notifies both you and the dentist. This gives you a chance to discuss the work and charges with your dentist before the work is performed.
If a lower cost alternative course of treatment would be medically appropriate, you might decide to proceed with the original treatment, or you might opt for the alternative course of treatment. That is a matter for you and your dentist to decide. Plan benefits are based on the actual work done or on the Plan's requirements relating to alternative course of treatment, not on the pre-determination. (See Alternative course of treatment under Annual Maximum in the Payments section).
Note: A pre-determination is processed much like a claim. Plan accordingly and allow sufficient time for that process to take place.