This section provides a comprehensive overview of the Scheme approved Dental Benefits Management, its activities and principles.
SHSB is responsible for the Management of dental benefits, claims, pre- authorisation and enquiries. Utilising internationally accepted clinical parameters ensures appropriate benefits to the members of Medical Aid Schemes.
- Dental benefits are paid at the BPOMAS Dental Tariff.
- Dental benefits are subject to Scheme rules and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application.
- Scheme Exclusions apply to dental benefits.
- In the event of a dispute, the Scheme rules will prevail.
Your Dental Benefits
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PREMIUM
Specialised Dentistry: P8,800
Basic Dentistry: Paid to the Overall Annual limit.
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HIGH BENEFIT
Specialised Dentistry: P7,260
Basic Dentistry: Paid to the Overall Annual limit.
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STANDARD
Specialised Dentistry: P3,500
Basic Dentistry: Paid to the Overall Annual limit.
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Consultations
Once every six (6) months per- beneficiary.
Covered at the BPOMAS Dental Tariff
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X-rays: Intraoral
Intra-oral radiographs complete series (8 peri-apicals)
Covered at the BPOMAS Dental Tariff
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X-rays: Extra-oral (Full mouth x-ray)
Once every six (6) months per beneficiary.
Additional benefit may be considered where specialised dental treatment is required where 2 extra-oral radiographs may be covered.
Covered at the BPOMAS Dental Tariff
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Preventative Care
Scale and polish treatments per beneficiary, once every six (6) months.
Benefit for fissure sealants: Limited to beneficiaries up to 14 years
Benefit for fluoride: Professionally applied fluoride limited to beneficiaries younger than age 3,18 years and older.
Covered at the BPOMAS Dental Tariff
Scheme Exclusions:
- Oral hygiene evaluation
- Tooth whitening
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Fillings
Benefit for fillings: Granted once per tooth every two (2) years
Covered at the BPOMAS Dental Tariff
Scheme Exclusions:
- Resin bonding for restorations that are charged as a separate procedure to the restoration
- The polishing of restorations
- Gold foil restorations
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Root Canal Therapy
Benefit subject to scheme rules and managed care protocols
Root canal treatment does not require pre-authorisation but the Invoice should be submitted with pre and post x-rays
Scheme Exclusions:
- Root canal therapy on primary (milk) teeth, it will only be covered when its pulpotomy
- A Root canal re-do by the same Practitioner is not covered
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Extractions
Surgical extractions, disimpaction & surgical removal of residual roots should be pre-authorised
Simple extraction does not require an authorisation
Emergency extractions are exempted from authorisation, however Invoices should be submitted with pre x-rays
Covered at the BPOMAS Dental Tariff
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Plastic Dentures and Associated Laboratory Costs
Full lower, full upper & full mouth dentures are covered every four (4) years, with two (2) repairs allowed in the first two (2) years and the last two (2) years
Partial dentures are covered every three (3) years, only one (1) repair after six (6) months
Pre-authorisation is required for an extra tooth to an existing denture
Covered at the BPOMAS Dental Tariff
Scheme Exclusions:
- Diagnostic dentures and associated laboratory costs
- Snoring appliances and associated laboratory costs
- High impact acrylic
- The cost of gold, precious metal, semi-precious metal and platinum foil
- Laboratory delivery fees
- Provisional dentures and associated laboratory costs
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Appliances
Mouth/ occlusal guard /bite plate
Requires pre-authorisation
Written clinical motivation and quotation
Covered at the BPOMAS Dental Tariff
Space Maintainer
Requires pre-authorisation
Written clinical motivation and quotation
Covered at the BPOMAS Dental Tariff
Specialised Dentistry limit as per overall Dental Benefit
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Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs
Pre-authorisation required
Quotation and & clinical motivation
Partial metal denture frames are limited to one (1) per jaw, i.e. two (2) per beneficiary, within a five (5) year period.
Metal base to partial dentures is limited to one (one) per jaw in a 5-year period.
Repairs to the metal base and replacement of lost dentures are not covered.
Covered at the BPOMAS Dental Tariff
Scheme Exclusions:
- High impact acrylic
- The cost of gold, precious metal, semi-precious metal and platinum foil
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Crown & Bridge and Associated Laboratory Costs
A bridge comprises two or more crown units. Each crown is payable from the available Dental benefit.
Pre-authorisation required
Quotation, clinical motivation & x-rays
Benefit for crowns is granted once per tooth every five (5) years
Covered at the BPOMAS Dental Tariff
Scheme Exclusions:
- Crown and bridge procedures for cosmetic reasons
- Crowns on milk teeth will not be covered
- Provisional/temporary crowns
- The cost of gold, precious metal, semi-precious metal and platinum foil
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Implants and Associated Laboratory Costs
Pre-authorisation required
The following must be submitted.
- Detailed quotation
- Periapical of the specific tooth or teeth area
- Written clinical motivation
- Tooth identification
Covered at the BPOMAS Dental Tariff
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Orthodontics
Pre-authorisation required
- Benefit for orthodontic treatment granted once per beneficiary per lifetime
- Benefit will not be granted where orthodontic treatment is required for cosmetic reasons.
- Transferred cases to a next provider - only the balance of the treatment plan will be covered.
- Members who default from initial treatment plan will not be re-admitted into treatment
The following must be submitted to authorise.
- Treatment plan
- Detailed quotation
- Panoramic radiographs
- Cephalometric analysis
- Photographs of face and teeth occlusion from the front and both sides
Non-fixed Orthodontics
Retainer
Requires pre-authorisation
- A detailed quotation and OPG radiograph must be submitted
Habit Breaker
Requires pre-authorisation
The following must be submitted:
- Detailed quotation
- Written clinical motivation
- Pictures
- OPG radiograph
Covered at the BPOMAS Dental Tariff
Scheme Exclusions :
- Orthodontic re-treatment after defaulting from initial treatment plan
- Invisible retainer material
- Active aligners
- Replacement of orthodontic appliances and remounting of orthodontic brackets are not covered.
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Periodontics
Pre-authorisation required
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Maxillo-facial Surgery and Oral Pathology
Emergency treatments are exempted from pre-authorisation
All hospitalisation treatments are subject to pre-authorisation and clinical appropriateness protocol.
Subject to Overall Annual Benefit limit per family
Covered at the BPOMAS Dental Tariff
In-hospital and specialised dentistry requires pre-authorisation which is obtainable directly from SHSB - failure to pre-authorise either in-hospital or specialist dentistry may result in rejection of claims. Above average benefits are offered for basic dentistry, promoting the dental philosophy of accessible primary care while specialised dentistry is benchmarked against industry and international parametres to evaluate clinical appropriateness before authorisation.
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Hospitalisation
Pre-authorisation required
- Hospital admission protocols apply
- Hospitalisation cover is provided for children below the age of 10 years when the treatment envisaged is of such a nature that it cannot be performed without general anaesthesia.
- Theatre visits for persons above seven (7) years for basic dentistry and extractions will not be covered
The payment of the dental procedure will be dependent on available benefits, and payable at the BPOMAS Dental Tariff
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Oral Hygiene/Prevention
- Oral hygiene instruction
- Oral hygiene evaluation
- Tooth whitening
- Nutritional and tobacco
- Cost of prescribed toothpastes, mouthwashes and ointments
- Fissure sealants on patients older than 14 years
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Fillings/ Restorations
- Resin bonding for restorations charged as a separate procedure to the restoration.
- Polishing of restorations
- Gold foil restorations
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Plastic Dentures/Snoring Appliances/Mouth Guards
- Diagnostic dentures
- Snoring appliances
- High impact acrylic
- Cost of gold, precious metal, semi-precious metal and platinum foil
- Provisional/temporary dentures and associated laboratory
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Partial Chrome Cobalt Frame Dentures
- High impact acrylic
- Cost of gold, precious metal, semi-precious metal and platinum foil
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Crown and Bridgework
- Crown and bridge procedures for cosmetic reasons and the associated laboratory costs
- Occlusal rehabilitations
- Provisional/temporary crowns
- Cost of gold, precious metal, semi-precious metal and platinum foil
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Veneers
- Porcelain veneers for cosmetic reasons
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Crown and Bridgework
- Orthodontic treatment for cosmetic reasons
- Orthodontic re-treatment
- Cost of invisible retainer material