If the charge for a dental service is expected to exceed $200 or if a dental exam reveals the need for fixed bridgework, you should notify CIGNA of such treatment prior to services being rendered. If requested, you must provide dental x-rays, study models or other information necessary to evaluate the treatment plan for purposes of benefit determination.

CIGNA will decide if the proposed treatment is covered under the Plan and estimate the amount of payment. The estimate of benefits payable will be sent to you and will be subject to all terms, conditions and provisions of the Plan. If a treatment plan is not submitted, the member will be responsible for payment of any dental treatment not approved. Clinical situations that can be effectively treated by a less costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure.

Pre-determination of benefits is not an agreement to pay for expenses. This procedure lets the you and the member know in advance approximately what portion of the expenses will be considered for payment.