Dental Plan – Breakdown For Providers

 ATTENTION NEW PROVIDERS:

W9 forms must be on file prior to payments being issued.

You can avoid payments being delayed by faxing your W9 form to (918) 280-4899

Submit Electronic Claims to…

Payor ID: PIBF

Group# P19926

Submit Paper Dental claims to:
PIBF
P.O. Box 211573
Eagan, MN 55121

For a More Detailed Breakdown, Click HERE.

Dental Breakdown PDF

PPO Network Name:

DNoA Preferred Network

Network Partners in DNoA Preferred Network

Dental Network of America (DNoA)
Dentemax
United Concordia
Careington

For assistance finding a participating provider visit www.dnoa.com or call 1-866-522-6758.

100% / No Deductible
Periodic Exam – every 6 mos.
Prophy – every 6 mos.

All Other Covered Services:
$100 DEDUCTIBLE PER PERSON PER CALENDAR YEAR
$1,000.00 MAXIMUM PER PERSON PER CALENDAR YEAR
EFFECTIVE 1/01/11 > NO YEARLY MAXIMUM FOR CHILDREN 18 AND UNDER
PAYABLE AT 80% IN-NETWORK / 70% OUT-OF-NETWORK

Other Services NOT Covered:

• ORTHODONTIC TREATMENT
• DENTAL IMPLANTS / BONE GRAFTS AND CROWNS FOR IMPLANTS
• TEMPORARIES AND TMJ
• NIGHT GUARDS FOR BRUXISM ONLY

There are no frequency limits
There is no missing tooth clause
There is no waiting period
There is no age limit for Fluoride treatment
There is no tooth limit for Sealant treatment
Posterior Composites are not downgraded
No limitations on anything except Exam & Prophy
Emergency/Problem Exams pay under Deductible/Co-Ins

SERVICES BEING DONE IN OP FACILITY:
A Letter of Medical Necessity stating why the dental services are being performed in an OP facility must be sent to PIBF for review and approval/denial
prior to services being performed

BENEFITS ARE DETERMINED ONCE THE CLAIM IS RECEIVED FOR PROCESSING

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