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., except in the case of emergency hospital admissions. Such emergency authorisation must be obtained within 48 hours or the following working day thereafter.
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.
+
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)
+
Restorations/fillings (Amalgam and Resin)
- Restorations/fillings (Amalgam and Resin)
- Benefits for fillings are available where such fillings are clinically indicated
+
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.
+
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.
+
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.
+
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
+
Crown & Bridges
- Benefit for crowns are granted once per tooth per five (5) years
+
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
+
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
+
Periodontics
- For a general dentist, restricted to non-surgical and root planning only
+
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).
+
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.