CareFirst Dental Manual

Membership and Product Information

Membership Card

A member's CareFirst or CareFirst BlueChoice identification card provides information about enrollment in a dental plan, which is indicated on the front of the card, as well as important telephone numbers and billing information, which are found on the back of the card. To verify a member's eligibility and benefits, call BlueLine when using your CFMI provider number, FirstLine when using your GHMSI provider number or your Regional provider number or call the Dental Business Operations department.

BluePreferred

CareFirst BlueChoice
The dental indicator is below the member's name

CFMI Dental Only
The dental indicator is below the member's name

Maryland Point of Service

NASCO

Preferred Provider Network

Traditional Indemnity
The dental indicator is below the member's name

FEP - There is no dental indicator on these cards, but dental benefits are included.

FEP Basic

FEP Standard

Regional Members
All Regional Traditional Dental members are identified by the DT indicator on their ID card. All Regional PPO members are identified by the DP indicator on their ID card.

Product Information

CareFirst Regional Traditional Dental (CFMI and GHMSI)
CareFirst Regional Traditional Dental members may seek treatment from any Regional Participating Provider in the network. Reimbursement is based on 100% of the Allowed Benefit (AB) with applicable deductibles and co-insurance. Members seeking treatment from non-participating providers receive 100% of the AB for covered services, but are subject to balance billing.

Traditional Indemnity Dental Products (CFMI and GHMSI)
Members may seek treatment from any Participating Provider in the respective network. Reimbursement is based on 100% of the AB with applicable deductibles and coinsurance percentages. Members seeking treatment from a non-participating provider receive 100% of the benefit available for covered services, but are subject to balance billing.

CareFirst Regional Preferred Dental (CFMI and GHMSI)
CareFirst Regional Preferred Dental Members may seek treatment from any Regional Preferred Dental Provider in the network. Reimbursement is based at 90% of the AB with applicable deductibles and coinsurance Members seeking treatment from regional participating (not a regional preferred provider) receive benefits at a reduced rate and are subject to balance billing up to the AB. Members seeking treatment from non-participating providers receive benefits at a reduced rate and are subject to balance billing.

Preferred Dental Product (CFMI)
The Preferred Providers are reimbursed at 90% of the AB with applicable deductibles and coinsurance percentages. This reimbursement level applies when services are provided to members covered under the Preferred Dental Product. Members seeking treatment from participating, but non-Preferred Providers, receive benefits at a reduced rate and are responsible for the difference between the amount paid and the AB. Members seeking treatment from non-participating providers receive benefits at a reduced rate and are subject to balance billing.

CareFirst BlueChoice Dental HMO
Members can select any provider that participates in The Dental Network as their primary care dentist. If members do not select a primary care dentist, one will be assigned. If a member needs to see a specialist for dental procedures, they should obtain a referral from their primary care dentist. For more information, contact The Dental Network.

CareFirst BlueChoice Discount Dental Network
This Discount Dental Network is a free discount program all CareFirst BlueChoice members have access to. Members can receive discounts on dental services through this program. Because it is a discount program and not a covered benefit, there are no claim forms, referrals or paperwork to fill out. Members must show their CareFirst BlueChoice ID card and pay the providers' fee at the time of service to save.

Dental Care Benefits

Dental care benefits are provided as defined in the members' contracts. The members' contracts may exclude or impose frequency limits on certain procedures such as restorations, periodontal or prosthetic services. Members' benefits may vary; to verify a member's eligibility and benefits, call BlueLine when using your CFMI provider number, FirstLine when using your GHMSI provider number or your Regional provider number, or call the Dental Business Operations department.

All dental contracts are subject to a benefit/annual program period maximum and lifetime orthodontia maximum:

• Benefit Maximum: A specified dollar amount restricting the plan's liability over a specific period of time, as applied to certain contracts or any segment of a contract. Members are responsible for charges incurred in excess of the benefit maximum.
• Lifetime Orthodontia Benefit Maximum: A specified dollar amount, which varies by contract, that the plan will pay for a member's orthodontic treatment in a lifetime.
  

Benefit Structure

Services are categorized according to Class or Level. Each Class/Level may provide benefits at different levels of coinsurance; this varies by account. The CFMI Traditional, CFMI Preferred, Regional Traditional and Regional Preferred Dental Products offer a full range of Class/Level structure. The standard structure is detailed below; some contracts may vary. Contact Dental Business Operations for specific benefit information.

Classes/Levels for members with GHMSI contracts may vary. Contact the Dental Business Operations unit for specific benefit information.

CFMI CLASS Contract Classification

• Class I Preventive/ Diagnostic: Exams, Radiographs, Prophylaxis, Fluoride,
  Sealants, Palliative Treatment, Space Maintainers.
• Class II Surgical Restorative: amalgam/ composite restorations, Simple and
  Surgical Extractions, Endodontic Therapy, Periodontic Therapy, Oral Surgery, General Anesthesia/ IV Sedation with Covered Oral Surgery.
• Class III Prosthodontics: Inlays, Onlays, and Crowns (not part of a bridge),
  Dentures (full and partial), Fixed Bridgework, including Crowns and Onlays (used as abutments or as a unit of the bridge), Repairs of Prosthetic Appliances, Denture Relining.
• Class IV Orthodontics.

CFMI LEVEL Contract Classification:

• Level I Preventive & Diagnostic Exams, Radiographs, Prophylaxis, Fluoride,
  Sealants, Palliative Treatment.
• Level II Amalgam/ composite restorations, Simple Extractions, Pulpotomy/ Root
  Canals, Repairs of Prosthetic Appliances.
• Level III Apicoectomy, Inlays, Onlays, Crowns (not part of a bridge), Space
  Maintainers, Surgical Extractions, Oral Surgery, General Anesthesia/ IV Sedation with Covered Oral Surgery.
• Level IV Dentures (full and partial), Denture Relining, Fixed Bridges, Crowns,
  Inlays and Onlays (used as abutments or as a unit of a bridge).
• Level V Periodontal Scaling/ Root Planing, Gingival Curettage,
  Gingivectomy/Gingivoplasty, Osseous Surgery, Mucogingival Surgery, Grafts, Occlusal Adjustments.
• Level VI Orthodontics.

Regional Dental Benefit Class Configuration

• Class I Preventive & Diagnostic Exams, Radiographs, Prophylaxis, Fluoride,
  Sealants, Palliative Treatment.
• Class II Basic Services: Amalgam/ composite restorations, non-surgical
  periodontics, simple extractions
• Class III Major Services, Surgical: Surgical periodontics, endodontics, complex
  oral surgery
• Class IV Major Services, Restorative: Inlays, onlays, crown, dentures, bridges,
  repairs of prosthetics
• Class V Orthodontics.