Form 210 - Dental Estimate printable pdf download

DENTAL COVER FOR CIVILIANS & THEIR DEPENDANTS AND FOR MILITARY DEPENDANTS

* This guidance does not apply to military active duty *

* You must ensure that the dentist you are visiting is in network with Dentemax. This should be

checked by contacting Dentemax ( or 1-800-752-1547), rather than asking

the dental office. If the dentist tells you they are in network and this is not confirmed by

Dentemax, you will be responsible for the full cost of your treatment. This includes referrals. The

specialist that your dentist has referred you to must also be in the Dentemax network *

* No routine dental care is funded during the first & last 3 months of your/your spouse’s tour *

Attending your appointment

· When asked for your insurance at the dental office, present your Meritain Health ID card.

Covered treatment

· See overleaf for a listing of covered adult and child treatments.

If you have any treatment that requires authorisation before approval has been received, or

you have any non-covered treatment, this will be a personal expense.

Authorisation process

· If the treatment recommended by your dentist requires authorisation from Meritain Health, they must

send x-rays and a treatment plan to Meritain Health:

Meritain Health

P.O. Box 27267

Minneapolis, MN 55427-0267

It takes around 2 weeks to receive a response from Meritain Health from the time that they receive

the case materials. The Healthcare Dept will inform you (or your spouse if you are a dependant) of

the decision. Meritain Health will also inform your dentist what treatment has been authorised.

· If the treatment requires authorisation from Defence Dental Services in the UK, a BDS-US Form 210

(included at the end of this handout) must be completed (page 1 by the employee, and pages 2-3 by

the dentist). The form, along with case materials including x-rays, clinical photographs, dental

models and a treatment plan must be sent to:

Healthcare Department

North American Support Group

British Defence Staff – United States

British Embassy

3100 Massachusetts Avenue NW

Washington, DC 20008-3600

It can take 4-8 weeks to receive a response from Defence Dental Services. The Healthcare

Department will notify you (or your spouse if you are a dependant) of the decision.

Emergency treatment

· All emergency work MUST be completed by a Dentemax dentist.

· All emergency treatment to relieve pain and discomfort (including temporary crowns) will be funded

without prior approval. Any follow up treatment, including permanent treatment, requires approval.

Charges

· Adults will be charged a co-pay for treatment. The remainder of the bill will be paid for by Meritain

Health. You will only be charged one co-pay for a course of treatment.

· There are 3 bands of co-pays (equivalent to NHS contributions in the UK) for adults (see overleaf).

· There are no co-pays for children. All routine children’s treatment will be paid for in full by Meritain

Health.

Form 210 - Dental Estimate

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