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Benefits

DC 37 Health & Security Plan Benefits

Dental Benefit

Contact the Inquiry Unit at (212) 815-1234 to determine your eligibility for this benefit and your benefit plan allowances.

Members who are eligible for a full dental benefit will be covered for 100% of the dental fee schedule. If you use a non-participating provider, you will be responsible for any difference between the Plan’s fee schedule and the dentist’s actual charges. Members who are eligible for a partial dental benefit will be covered for 75% of the dental fee schedule and will be responsible for the additional 25%. If you use a non-participating provider, you will be responsible for any difference between the Plan’s fee schedule and the dentist’s actual charges, in addition to the 25% of the allowable amount.

DC 37 Dental Centers

Manhattan Center
115 Chambers Street
New York, NY 10007
Tel. (212) 766-4440

Brooklyn Center
186 Joralemon Street
Brooklyn, NY 11201
Tel. (718) 852-1400

Maximum Benefit

In all cases should you obtain treatment that is restricted, has a frequency limitation, is a non-covered procedure or if you go over the yearly maximum, you will be responsible for any additional costs incurred. The yearly maximum benefit is $1,700 per calendar year, based on the Plan’s fee schedule. You have the right to opt-out of the Plan’s dental benefit coverage. Please call the Plan at (212) 815-1234 for more information. In all circumstances, Plan rules regarding restrictions, limitations, and annual dollar limit will apply.

Mandatory Pre-Authorization

Pre-authorization is mandatory before beginning treatment for prosthetics (dentures and bridgework), single crowns, extensive gum treatment, TMJ therapy, root canal therapy or orthodontics. YOU MUST submit a Pre-Authorization Plan.

This pre-authorization is for your benefit. You get a free second professional opinion to determine if the work is necessary. In addition, you will have advance notice of the extent of the work involved- dentally and financially.

YOU MUST SUBMIT A PRE-AUTHORIZATION PLAN FOR THE ABOVE LISTED SERVICES OR YOUR CLAIM WILL BE REJECTED.

On the American Dental Association (ADA) form, available at the Plan Office or on this website, your dentist will describe the proposed work, and attach x-rays to show that the work is needed.

You and your dentist should complete the form and send it to the Plan Office. The Plan Office reviews the pre-authorization plan, then notifies you and your dentist if the intended work is covered and for how much. THIS ASSUMES, OF COURSE, THAT YOU ARE ELIGIBLE FOR BENEFITS WHEN THE WORK IS PERFORMED, and takes into consideration the Plan’s rules and regulations regarding yearly maximums and frequency limitations for certain procedures. There are no appeals for proposed treatment (pre-authorization) that have been rejected by the Plan. If the dentist disagrees with the treatment authorized in the pre-authorization response, the dentist should write to the Professional Review Unit and send in any additional information justifying why he/she thinks the procedure should be done.

New Dental Claim Forms (ADA)

Effective Jan. 1, 2014, the Dental Unit will only accept the ADA claim form (PDF) or the DC 37 Pre-authorization Plan Response form from your dentist’s office. The ADA forms are available at the Plan office or on this website. The ADA form is a one-page form, with information about filing claims on the back in both English and Spanish. The ADA form has to be completed by the member and the dentist. All required signatures are located in box #36, #37 and #53 of the ADA claim form. The member and dentist sign only one box, whether the claim is for a Pre-Authorization or Claim for Completed Services. If the claim(s) is for completed services, then the member must indicate that the payment is to be made to either the member or dentist by signing in box #36 or #37. You can download the ADA claim form here (PDF) or request the forms be sent to you by calling the Plan’s Inquiry Unit Forms line at (212) 815-1531.

Claims
Continuation of Treatment

If you are terminated from employment for any reason except total disability- (members receiving Disability Benefits are eligible for Health & Security Plan benefits up to a maximum of three months for part time benefits or six months for full time benefits, from the date of their disability)- while you are having dental work done, the Plan will continue to cover certain services* already begun up to 60 days after termination. This is also true for your spouse (including domestic partner or partner in a civil union) and eligible dependents.

* Only Orthodontics, prosthetics or root canal therapy.

Inquiries

For information relating to dental pre-authorizations and claims, you should contact the Inquiry Unit at 212-815-1234. The yearly maximum benefit is $1,700.

Guidelines of the Plan’s Dental Services

In all circumstances, Plan rules regarding restrictions, limitations and annual dollar limit will apply.

Coverage Exclusions
Dental Centers

In addition to using any licensed dentist or a dentist from the Plan’s list of Participating Panel Dentists, a member and/or dependents may also obtain treatment at either of the two dental centers. The same Plan rules regarding: restrictions, limitations and/or annual dollar limit will also apply. The individual who obtains treatment at the Plan’s Centers will be required to comply with the policies and regulations established by the Center for its patients.

Active and retired members covered by the DC 37 New York Public Library Health and Security Plan Trust and the DC 37 Cultural Institutions Health and Security Plan Trust are not eligible for dental services at 115 Chambers Street and 186 Joralemon Street.

Dental Center Policies

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