Cigna Prepaid High (K1I09) is a new dental plan for 2021. WAOV9 CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This P atient Char ge Schedule lis ts the benefits of the Dental Plan including covered procedures and patient charges. ��� $0 fee for all office visits per patient, per office visit, plus any other applicable patient charge. If CF is $50 for that service and the coinsurance is 50%, Cigna will pay $25 and you will pay $25. Cigna Sanction ��� CMS. CIGNA DHMO K1-09 Exclusions And Limitations LIMITATIONS ON COVERED SERVICES Listed below are limitations on services covered by your Dental Plan: 1. Important Highlights ��� This P atient Char ge Schedule applies only when c overed dental servic es are performed by your Network Dentist, unless otherwise authorized -2-CIGNA Dental Care® Patient Charge Schedule (DC-07) Code Procedure Description Patient Coinsurance Office Visit Fee (Per Patient, Per Office Visit in Addition to Any Other Applicable Patient Charges) Office Visit Fee $5.00 Diagnostic/Preventive ��� Oral Evaluations are Limited to a Combined Total of 4 of the Following Evaluations During a 12 Consecutive Month Period: Periodic Oral For example, an out-of-network provider may charge $100 to fill a cavity. Cps enrollment 2021. cps enrollment 2021 Some high schools consider attendance during the application and selection process. Patients pay the patient charges listed only when the procedures are performed by a network dentist. 2. Option Period is October 1 st through October 31 st , 2020. A fee schedule is a complete listing of fee maximums used by Medicare to pay physicians, other enrolled health care professionals, or providers/suppliers on a Fee-For-Service (FFS) basis. Pre-K Enrollment Process (SY20-21) Children must be three or four years old, but not yet five years old, on or before September 1st, in order to be age eligible for a CPS preschool program. cigna dental care® patient cHarge scHedule ��� This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Your Patient Charge Schedule lists any limitations on frequency. Important Highlights This Patient Charge Schedule applies only when covered dental services are Cigna Provider Directory HMO Plans Copayment and Fee Schedule. Important Highlights ��� This P atient Char ge Schedule applies only when c overed dental servic es are performed by your Network Dentist, unless otherwise authorized Jan 21, 2016 Health and Life Insurance Company, ... to be incidental to and part of the charges for services provided and not separately chargeable. Frequency - The frequency of certain Covered Services, like cleanings, is limited. Cigna Dental contracts with network dentists in most areas of the country. ��� Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. The annual fee of $14.40 usually charged for the card has been paid on behalf of the employee by the Employees Benefits Department. Procedures performed by an out-of-network dentist are not covered, and patients will be charged the dentist's usual fee for those procedures. Your Patient Charge Schedule lists the benefits of the Cigna Dental HMO, including covered procedures and patient charges. A2I09 CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This P atient Char ge Schedule lis ts the benefits of the Dental Plan including covered procedures and patient charges. Page 1 Cigna Dental Care (DHMO*) ��� Patient Charge Schedule OIV Series for Certain State of Olahoma Employees ��� Plan effective 01/01/2017 Listed on the following pages of this Patient Charge Schedule are charges to be paid directly to you by the member for specific procedures. cigna dental care ��� Patient charge schedule 09 series ��� standard copays ... Procedure Code1 G1-09 G1-V9 W1-09 W1-V9 L1-09 L1-V9 K1-09 K1-V9 F1-09 F1-V9 F7-09 F4-09 B1-09 K1I09 F1I09 B1I09 Office visit fee (Per patient, per office visit in addition to any other applicable patient charges) K1I09 92249.a Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. CIGNA Dental Care Patient Charge Schedule Comparison K1-09 vs. WAO09 Office visit fee (Per patient, per office visit in addition to any other applicable patient charges) Diagnostic/preventive ��� Oral evaluations are limited to a combined total of 4 of ��� ��� Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract. what Cigna will pay for that service after coinsurance and Contracted Fee (CF), or Maximum Reimbursable Charge (MRC) in AK and MA, have been applied. charge or MPFS amount. You can request a list of network dental offices in your area by calling Cigna Dental at 1 (800) Cigna24 (1 (800) 244-6224). Don't forget to enroll online. ��� The plan is based on a fee schedule negotiated by Cigna Dental rather than usual network fees. Network dentists provide covered services to Cigna Dental HMO members at independently owned network dental offices. ��� Example services/copays: Amalgam, one surface, permanent teeth: $0 copay Root Canal, Anterior: $210 copay 92249 856616 02/13 F4-09 F4-09 cigna dental care® (*dHMO) patient cHarge scHedule This Patient Charge Schedule lists the benefits of the Dental Plan including Important Highlights ��� This P atient Char ge Schedule applies only when c overed dental servic es are performed by your Network Dentist, unless otherwise authorized cigna dental care® patient cHarge scHedule Code Procedure Description Patient Charge D6242 Pontic ��� Porcelain fused to noble metal $460.00 D6245 Pontic ��� Porcelain/ceramic $480.00 D6602 Inlay ��� Cast high noble metal, 2 surfaces $470.00 D6603 Inlay ��� Cast high noble metal, 3 or more surfaces $490.00 K1I09 AZ CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This P atient Char ge Schedule lis ts the benefits of the Dental Plan including covered procedures and patient charges. 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