PROVIDER

• Two (2) annual checkups 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)

• Benefits for fillings are available where such fillings are clinically indicated

• Intra -oral radiographs complete series (8 per beneficiary unless motivated.
• Infection control (tariff code 8109) only 2 per visit.
• Local anaesthetic (tariff called 8145) only three (3) per visit.

• 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 sealantS are covered up to (14 years)(tariff code 8163)
• Fissure sealant limited to permanent molars and pre-molars. Not within Two (2) years of previous treatment.

• Subject to pre-authorisation and treatment protocols
• 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.

• 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.
• Pulp removal/emergency root canal treatment not allowed on the same day as root canal treatment

Pre-authorisation and x-rays are required

• Benefit for crowns is granted once per tooth per five (5) years

• Metal framework every five (5) years.
• Full acrylic dentures every five (5) years
• Partial acrylic dentures every four (4) years or subject to pre-authorisation

Pre-authorisation required

• 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

Pre-authorisation required

• For a general dentist, restricted to non-surgical and root planning only

Pre-authorisation required

• Subject to Overall Annual Hospital limit per family per annum.
• Benefit is strictly only for cases of children under 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).

Subject to pre-authorisation and clinical appropriateness protocol

• 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.

• The surname and initials of the member.
• The first name of the patient as indicated on the membership card.
• Date of birth of the patient.
• The membership number of the member.
• The practice code and name of the service provider rendering the service.
• The date on which the service was rendered.
• The nature of the service and international classification of disease (ICD) and/or current procedural terminology (CPT), called a diagnosis code from time to time.
• Providers should submit invoices written in English.
• The code number of the item of the recognised tariff, where applicable
• Where the account is a photocopy of the original, certification by the service provider by way of the rubberstamp and signature of such a photocopy.

• SHSB reserves the right to return to the service provider all claims, either not submitted in the prescribed format or not legible.
• Where any account has been paid for by a member, the member shall, in support of his claims, submit a receipt as proof of payment.
• The Management Committee may require that, where possible, a claim should be certified by the member.
• Dental claims submitted after a period of 3 months will be considered stale and will not be considered for payment.
• The liability of the scheme to process claims resubmitted for whatever reason shall lapse three (3) months following the date on which it was first assessed or paid.
• Foreign claims submitted after the three (3) months stale period must be escalated to the scheme.

• Cosmetic dentistry such as bleaching and laminated veneers where not clinically indicated but purely aesthetic.
• Mouthwash and toothpaste.
• Fissure sealant on patients older than 14 years.
• Professionally applied topical fluoride in adults eighteen (18) years and above
• Extra oral/facial image of dentist work not covered, except only for orthodontics and fluorosis.
• Periodontal chip.
• Ozone therapy.
• Therapy of healed extraction site.
• Vascular surgery for the treatment of headaches.
• Oral appliances or the ligation of temporal arteries for treatment of headaches.
• For multiple charges of desensitising, resin or medicament, only application of desensitising medicament per visit will apply once-off.
• Desensitising, resin or medicament, will not be covered during the same visit as application of topical fluoride.
• Full endodontic procedures are not covered on primary teeth.
• Emergency root canal/pulp removal (pulpectomy) charged on the same day as complete root canal therapy.
• Snoring/anti snoring device or device for sleep apnoea manufactured by a dental provider or laboratory.
• Crowns used to restore teeth for cosmetic reasons.
• Crowns where the tooth has recently been restored to function successfully within six (6) months.
• Laboratory fabricated crowns are not covered on primary teeth.
• Crowning of teeth involving failed RCT.
• Temporary/provisional and emergency crowns including lab costs.
• Acrylic crowns, including laboratory aspects, placed for any reason are excluded from benefits.
• Fixed prosthodontics where the members mouth is periodontally compromised.
• Crowns on periodontally compromised teeth.
• Bridges where abutments are periodontally compromised.
• Crown and bridgework on teeth with compromised root canal treatment e.g. half- filled canals.
• Fixed prosthodontics used to restore teeth for cosmetic reasons.
• Benefit for the cost of metal would be in accordance with the tooth type.
• Cost of gold, precious metal, semi-precious metal and platinum foil.
• Laboratory costs where the associated dental procedure is not covered.
• Anterior in-lays and on-lays made of metal alloy e.g. gold, will not be covered.
• Diagnostic dentures.
• Metal base to full dentures.
• Orthodontic re-treatment.
• Orthodontic retainer/fixed/removal appliances repairs.
• Diagnostics set up (orthodontics).
• Surgical periodontal services in hospital.
• Gingivectomy in hospital.
• Dentectomies in hospital.
• Frenectomies in hospital.
• Fillings, extractions and root canal therapy in-hospital for children over the age of ten (10) years, or subject to approval by SHSB.
• Preventative dentistry procedures in hospital.
• Dental implants in or out of hospital and associated surgical procedures are covered subject to annual financial limits.