Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.
- International/foreign treatments require pre-authorisation.
- Pre-authorisation is required for: dentures (six unit or more acrylic (plastic) dentures, cobalt-chrome) Crowns & Bridges, extractions (surgical, impacted, residual roots), implants, orthodontics, inlays, appliances, periodontics, hospital admissions and conscious sedation in the dental rooms.
- Failure to pre-authorise orthodontic treatment will result in a payment only from date of authorisation for the remaining months of treatment, provided that the treatment is approved as per the managed care protocols.
- Pre-authorisation does not apply to emergency hospital admission. Invoices must be submitted separately and promptly accompanied by motivation.
- Pre-authorisation policy and procedures applicable to all schemes and options will be subject to available benefits.
- Pre-authorisation must be obtained within 48 hours for the following clinical services and will be subject to benefits availability and all required clinical information, before treatment commences.
Pre-authorisation requirements and supporting documentation must be emailed to dental@shsbotswana.co.bw. Once authorisation is complete, SHSB will send a letter of benefit allocation back to the service provider.
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Dental Consultation - Annual check-up
- Two (2) annual check -ups per beneficiary, one (1) every six months
- Examination or consultation for a specific problem (tariff code 8104), not requiring charting and treatment planning not within four (4) weeks of (tariff code 8101)
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Restorations/fillings (Amalgam and Resin)
- Restorations/fillings (Amalgam and Resin)
- Benefits for fillings are available where such fillings are clinically indicated
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Diagnostics
- Intra -oral radiographs complete series (8 peri-apicals) not covered (tariff code 8108), except for periodontal treatment;
- Panoramic radiograph only 1 in six months per beneficiary unless motivated;
- Infection control (tariff code 8109) only 2 per visit;
- Local anaesthetic (tariff called 8145) only three (3) per visit.
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Preventative Dentistry
- Scale and polish once every six (6) months (tariff code 8155/8159);
- Fluoride treatment only members between three (3) and eighteen (18) years (tariff code 8161)
- Fissure sealant only members between six (6) and sixteen (16) years (tariff code 8163)
- Fissure sealant limited to permanent molars and pre-molars. Not within Two (2) years of previous treatment.
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Dentures
- One (1) set of full, or upper, or lower plastic denture every four years, or subject to approval;
- Relines, Rebase, Soft Base every two (2) years;
- One partial plastic denture for jaw per beneficiary every four years or subject to approval.
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Endodontic therapy (Root Canal Treatment)
- 4 periapical x-rays covered
- 8132 to help removal/emergency root canal treatment not allowed on same day as root treatment
- Direct or indirect pulp capping (tariff code 8301/8303) excluded from benefit;
- Root canal treatment on primary and wisdom teeth excluded from benefit;
Specialised Dentistry limit as per overall Dental Benefit
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Crown & Bridges
- Benefit for crowns are granted once per tooth per five (5) years
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Dentures
- Metal frame work every five (5) years
- Full acrylic dentures every five (5) years
- Partial acrylic dentures every four (4) years or subject to pre-authorisation
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Orthodontics
- Pre-authorisation is required for orthodontic treatment subject to available limited dentistry limit
- Re-treatment of orthodontics is not covered
- Loss of appliances, repair, remounting or replacement of fixed orthodontic brackets is not covered
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Periodontics
- For a general dentist, restricted to non-surgical and root planning only
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Dental Hospitalization
Pre-authorisation required
- Subject to Overall Annual Hospital limit per family per annum;
- Benefit is strictly only for cases of children below ten (10) years - subject to scheme approval;
- Multiple hospital admissions will not be covered and will only be authorised once in a lifetime, or subject to approval by scheme;
- No benefit for preventative procedures in hospital (fissure sealant, fluoride treatment and polishing of teeth for children below ten (10) years).
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Maxillo-Facial and Oral Surgery
Pre-authorisation required
- Subject to Overall Annual Benefit limit per family;
- Benefit only for removal of symptomatic impacted wisdom teeth (3rd molars) associated with pain and pathology, only if pre-authorised as a day case;
- Clearly defined radiographs required with authorised submission.