Guardian Managed DentalGuard Pre-paid HMO

This managed care dental plan is a dental HMO. Participants must seek services from a primary care dentist. You must receive a referral from your primary care dentist to seek the services of a specialist. Payment for services rendered is based on a schedule of patient charges as outlined in the certificate of coverage.

Managed Dental FAQs

Can I visit any general dentist I want under the Managed DentalGuard Pre-paid HMO plan?

To have your dental services covered, you must go to the dental office that you choose when you enroll. You can find a conveniently located dentist in the Managed DentalGuard Directory of Participating General dentists. All of your dental care will be provided by, or arranged by, your selected dental office.

What if I want to change my dental office after I've picked one? Is there a limit to how many times I can change?

You can change dental offices just by calling Guardian at (888) 618-2016. The change will be effective on the first day of the next month, as long as you call before the 20th day of the month. There's no limit on the number of times you can change dental offices, but selections are always effective from the first day of a month to the last day of a month. Any services started at one dental office must be completed by that office, and your account with the first office must be paid in full before a transfer can be processed.

Does the whole family have to use the same dental office, or can my dependents choose a different one?

Each family member can enroll with a different dental office.

What if I need to see a specialist?

The Managed DentalGuard network includes oral surgeons, periodontists, endodontists, orthodontists and pediatric dental specialists. If you need dental services that only a specialist can provide, your dental office will request authorization from Guardian for you to see a participating specialist. (Usually your dental office will have the referral authorized within ten days; if it's an emergency, it is faster.) You will be responsible for the patient charge shown in your booklet for any covered services performed by a specialist dentist.

I've taken my five-year-old to a pediatric dentist. Can I do that with Managed DentalGuard?

Your child must first be seen by a general dentist at your selected dental office. If a child under age six is unmanageable, a referral to a pediatric dental specialist may be made. After the child's sixth birthday, pediatric specialty services will not be covered.

What is meant by the term "patient charge"?

With the Managed DentalGuard Pre-paid HMO plan, most diagnostic and preventive services are covered at no cost to you. However, for basic, major and some preventive services, you will pay a certain amount -- which is referred to as a patient charge -- for each covered service you receive. The patient charges for your PPD plan are listed in your certificate of coverage booklet, so you'll always know what you'll have to pay for services you need. Better yet, with the Managed DentalGuard Pre-paid HMO plan there are no deductibles, annual maximums or co-insurance -- plus no pre-treatment reviews are required for services provided by your participating general dentist.

When I visit a dentist, are there any claim forms to fill out?

No. Under the Pre-paid plan, any necessary paperwork for services from participating dentists is handled by your selected dental office. You just show your Managed DentalGuard Pre-paid HMO ID card.

What if I have a problem with my dentist, or with my coverage?

Call Managed DentalGuard Member Services and discuss your problem with the representative. He or she will work with you to help you resolve your problem. If you are still unsatisfied, you can submit a grievance form explaining the matter. Member Services, your dental office or your employer can provide a form for you to use. Guardian keeps track of all grievances, and regularly reviews grievance reports to identify potential problem areas. When will my coverage go into effect? Your benefits coordinator will notify you when your coverage takes effect.

What happens if a member wants a more expensive service than the one the plan covers, or that the dentist recommends?

Most indemnity and PPO plans cover the least expensive treatment appropriate for your condition. Even if your dentist feels a more expensive treatment would be better for you, these plans pay for the less expensive treatment, and you have to pay the difference between what the plan pays for the less expensive treatment and what the dentist charges for the more expensive treatment.

Under the Managed DentalGuard Pre-paid HMO plan, the covered service that the participating dentists recommends is provided at the defined patient charge, regardless of the relative cost. So you are never caught between what your dentist recommends and what the plan covers.

If you want a more expensive, but still covered, treatment than the one that your participating dentist recommends, then you are responsible for the patient charge for the recommended service, plus the difference between the dentist's fees for the two procedures.

How are patient charges for specialty care determined?

Covered specialist services are listed in your certificate of Coverage, along with the specific patient charge for each service. You generally pay a higher patient charge when a service is performed by a specialist than if the same service were performed by a general dentist. However, unlike most plans, the Managed DentalGuard Pre-paid HMO plan always tells you exactly what the patient charge for covered specialty care will be. There are some services that are not covered if performed by a specialist.

Managed DentalGuard plans have defined, a specific patient charges for covered specialty care services. Most other optional plans offer specialty care at a percentage discount off of the specialist's usually fee, which is not defined.