Aetna Dental Frequently Asked Questions (FAQs)
In a DMO (Dental Maintenance Organization), an enrollee selects a participating Primary Care Dentist (PCD). Their primary dental care is provided by their PCD and only at locations that participate in the plan. Though the choice of providers is minimal, a DMO tends to cover a greater range of services at lower co-pays than traditional dental plans.
Yes, you will receive an ID card. Your card will list all eligible family members (up to 5) and their Primary Care Dentist (PCD). However, you may not receive cards if you do not choose a PCD.
A Primary Care Dentist (PCD) is a dentist you choose to manage your overall dental care. All Aetna DMO enrollees are required to select a PCD. To select your PCD, visit Aetna's online Provider Directory or contact Aetna's Member Services at 877-238-6200.
Each dependent has to select a PCD. They can assign to a different DMO general dentist, but no person can elect a specialist, including a pediatric dentist, as their general dentist.
Yes, you can nominate your current dentist for consideration to join the Aetna provider network by calling Aetna's Member Services at 877-238-6200. Requesting to nominate, however, does not guarantee that your dentist will apply to or be accepted as an Aetna provider.
Yes. It is recommended that you switch your Primary Care Dentist (PCD); you can switch your PCD as often as every 30 days. If you do not switch your PCD, all services may not be covered unless considered an emergency.
When you contact Aetna between the 1st and 15th of the month, your dentist choice or dentist change will become effective the first calendar day of the following month (e.g., You call Aetna on January 5th, dentist choice becomes effective February 1st). If you contact Aetna between the 16th of the month through the end of the same month, your dentist choice or dentist change will become effective the first calendar day of the second month (e.g., You call Aetna on January 18th, dentist choice becomes effective March 1st).
The general dentist is technically responsible for all treatments. Suppose they feel that the service is beyond the scope of their ability. In that case, the office should submit to Aetna a pre-authorization listing the treatments needed and why they cannot perform them, attaching all needed diagnostic materials to support the treatment and to whom they wish to refer the patient. Aetna will review and decide on coverage based on this information. However, the Primary Care Dentist (PCD) can "directly refer" members for certain services to a participating Specialty Dentist. In those situations, a pre-authorization request is not required. The PCD should review the list of services and conditions to identify if the service is eligible for "direct referral." If so, the PCD selects a participating Specialty Dentist to whom the patient is to be referred and completes the Specialty Referral Form. Direct referrals may be made only to participating providers.
Aetna must permit the member to receive treatment from a non-participating dentist when no participating dentist is available. Aetna cannot limit the total fee charged for the case since there is no contractual agreement with that dentist. Aetna is not obligated to pay more than the covered percentage of the case fee. However, we do not wish to penalize the patient because we cannot locate a participating orthodontist. Therefore, the member's out-of-pocket may be, at most, an amount equal to what the co-payment would have been based on the PPO fee schedule for an orthodontist. This would be a specialty fee schedule. The balance will be paid even though it may exceed the standard covered percent of the dentist's charge.
The patient can see a participating orthodontist without a referral.
No. However, the plan would cover the contracted fee for conventional orthodontic applicants. The member would be responsible for their standard co-payment for the conventional appliance plus the difference between the contracted fee for the conventional appliance and the dentist's fee for the ceramic/clear/lingual/Invisalign appliance.
No. Replacement or re-cementation of an appliance due to patient abuse or non-compliance after the third re-treatment is ineligible based on the reasonably necessary provision. Separate expenses for lost or stolen appliances and retainers are not covered. The patient is responsible for these charges, however, minor repairs necessary due to normal wear are covered.
No. However, benefits are available for the related prosthesis (after the implant). If the patient elects the implant and the related prosthetic procedures, then the patient is responsible for the total cost and co-payment for the prosthetic. For example, if a tooth is extracted and an implant is placed, the co-payment for the crown over the implant is calculated based on the dentist's fee for a crown placed on an implant. The patient is responsible for the total cost of any related procedures provided solely in connection with the implants, including follow-up procedures.
Coverage for the first installation of removable dentures and fixed bridgework are eligible, if needed, to replace one or more natural teeth that were removed while this policy was in force for a covered person. However, it is essential to note that the teeth should not be abutments to a partial denture, removable bridge, or fixed bridge installed during the prior five years.
Pediatric dentists are specialists, but the Primary Care Dentist (PCD) may directly refer to a participating Specialty Dentist for consultation or problem-focused examination for children under age six if (a) the PCD has documented at least one unsuccessful attempt to treat the child and (b) at least one of the following conditions is present: the child has an existing medical condition or is developmentally disabled; presents a behavioral management problem; has extensive tooth decay; or requires emergency care that is beyond the scope or ability of the PCD. All other conditions or procedures not indicated must be pre-authorized by Aetna. This includes referrals for children age six or older with a medical condition, a significant behavioral management problem, and severe tooth decay that may require referral to a Specialty Dentist. Only when the referral is authorized will the consultation be covered.
No. Once the Primary Care Dentist (PCD) approves a referral to a contracted pediatric dentist, the child can continue to be treated by the pediatric dentist until the age of six without additional referrals from the PCD.
No. The Primary Care Dentist (PCD) is responsible for performing root canal treatments on anterior (front teeth) and pre-molar (bi-cuspid) teeth. Your PCD may also perform root canal therapy on your molar teeth or directly refer you to a participating specialty dentist for the following conditions or treatment; the specialty dentist may render treatment without pre-authorization for consultation or problem-focused examinations, molar root canal therapy, and root canal re-treatments.
Emergency care must be rendered to alleviate pain and/or prevent the worsening of a condition that would be caused by delay. The Primary Care Dentist (PCD) is responsible for taking all appropriate steps to alleviate the pain or provide palliative treatment, whenever possible. Once the patient's condition stabilizes to the degree possible, referral to a specialty dentist may be appropriate in certain circumstances.
In the event of an emergency, and the Primary Care Dentist (PCD) cannot see or treat a patient, the member must contact Aetna before being seen by another provider to authorize palliative treatment. Palliative treatment authorization may only be provided if the member indicates pain, swelling, and/or bleeding.
