the premier choie i detal & visio beeits member guide ... · neto k deist ueas a Ç detal ae...

ARGUS DENTAL & VISION, INC. Toll F ee - - | West State St eet | Ta pa, Flo ida | .a gusde tal isio . o

MP Maste Pla I di idual Me e Guide /

ARGUS DENTAL & VISION, INC. Toll F ee - - | West State St eet | Ta pa, Flo ida

MasterPlan Member Guide

For Individuals & Families

The Premier Choi e i De tal & Visio Be efits




Welcome to Argus Dental & Vision!

Tha k ou fo hoosi g A gus De tal & Visio as ou health a e pa t e . The A gus tea o ks a efull to

deli e supe io e efits that a e desig ed ith ou e e s i i d a d to p o ide ou the est optio s

ased o ou spe ifi eeds. Ou suppo t s ste s ha e ee de eloped to deli e the ualit ou e ui e

a d e pe t f o ou e efits e pe ts.

As ou a igate th ough ou e e efits, e hope ou’ll fi d the i fo atio i this guide helpful. We

pla e high p io it o aki g e tai ou ha e a supe io usto e e pe ie e e e ti e ou e gage ou

o pa . Ou tea of k o ledgea le se i e p ofessio als is eage to assist ou ith a uestio s o o -

e s.

We e og ize ou ha e a othe hoi es. Tha k ou fo pa t e i g ith A gus De tal & Visio . We look

fo a d to ea i g ou t ust a d o fide e to ai tai a ea s of se i e to ou fo ou de tal a d

isio a e.

Best Rega ds,

Ni holas M. Ka ouklis, DMD

CEO & P eside t



F e ue tl Asked Questio s

What is the e efit of pa ti ipati g i the Maste Pla ?

The Maste Pla p o ides full o e age o a ious p e e ti e a e de tal se i es he ou o tai de tal a e f o a Net o k De tist. I additio , ou a e e titled to e ei e u e ous othe de tal a e se i es ide tified i the S hedule of Be efits i e ha ge fo the appli a le Co-pa e t ide tified i the S hedule of Be efits he ou isit a Net o k De tist.

What de tal se i es a e a aila le u de the Maste Pla ?

The S hedule of Be efits set fo th o pages - of this Maste Pla Me e Guide ide tifies the u e ous o e ed se i es a aila le u de the Maste Pla , as ell as the Co-pa e ts appli a le to ea h su h se i e.

What if a pa ti ula de tal se i e is ot listed i the S hedule of Be efits?

Ge e all , de tal se i es that a e ot listed i the S hedule of Be efits a e a aila le at a % dis ou t off of the Net-o k De tist’s o al/ usto a ha ge. Ho e e , the e a e so e de tal se i es that a e ot su je t to a dis ou t

a d a e ot othe ise a aila le u de the Maste Pla . Please efe to the Li itatio s a d E lusio s se tio of the S hedule of Be efits.

Ho do I sele t a Net o k De tist?

You a isit .a gusde tal isio . o ou e site to fi d a Net o k De tist i ou a ea, o ou a o ta t A -gus Custo e Ca e at . . . .

Ho do I ha ge add ess o o ta t i fo atio ?

To update ou add ess o o ta t i fo atio , please o ta t A gus Custo e Ca e at . . . .

Who do I o ta t if I ha e uestio s ega di g the Maste Pla ?

Please o ta t A gus Custo e Ca e at . . . .

Ho do I ake a de tal appoi t e t?

To ake a appoi t e t, si pl o ta t the Net o k De tist that ou ha e sele ted. Whe ou all the de tist’s offi e, ou should ide tif ou self as a A gus Maste Pla e e , a d p o ide the de tist’s offi e ith ou effe ti e date of o e age a d the u e o ou Maste Pla ID a d. Be su e to p ese t ou A gus Maste Pla ID a d o e

ou a i e at ou s heduled appoi t e t. You ill also e e ui ed to p ese t a photo ide tifi atio a d at ea h ap-poi t e t.

Ca I ha ge de tist?

Yes, ou a ha ge ou de tist at a ti e* alli g A gus Custo e Ca e at . . . . Re uests ade p io to the th of da of the o th ill e effe ti e o the st of da of the follo i g o th. *P o ided ou do ot ha e a outsta di g fi a ial o ligatio to ou o igi al de tist.



What if I eed spe ialt a e?

You ha e a ess to spe ialists i all fields of de tist at edu ed ates th ough ou Maste Pla . A gus e o e ds that ou isit ou usual Net o k De tist fo a app op iate diag osis p io to isiti g a spe ialist. Ho e e , au-tho ized efe als f o A gus a e ot e ui ed p io to seeki g spe ialt a e. If ou e ei e de tal a e f o a Net o k De tist, the Co-pa e ts ide tified i the S hedule of Be efits do ot appl . I stead, the

se i es of the spe ialist ill e p o ided at a dis ou t of % off of the Net o k spe ialist’s o al/ usto a ha ges. If ou e ei e spe ialt de tal a e f o a spe ialist ho is ot a Net o k De tist, ou ill ot e ei e

a dis ou t o the se i es. Rathe , ou ill e o ligated to pa the ates ha ged the o -Net o k De tist ho p o-ide ou spe ialt a e.

What if I ha e a De tal E e ge ?

Befo e a De tal E e ge a ises, please o ta t ou Net o k De tist to fi d out ho he o she should e o ta ted if ou eed u ge t a e t eat e t o t eat e t afte o al offi e hou s. Ou Net o k De tists ha e thei o pla fo ho the a e ea hed i ase of e e ge , o the ill ake p io a a ge e ts ith othe de tists if the a e u a aila le to p o ide a e to ou i ase ou eed t eat e t i ediatel o u ge tl .

If ou ha e a De tal E e ge , please o ta t ou Net o k De tist o A gus Custo e Ca e at . . . . If ou e e ge o u s afte egula usi ess hou s, please o ta t ou Net o k De tist. If ou a e u a le to ea h ou Net o k De tist, please all .

De tal E e ge se i es ill e o e ed u de the Maste Pla if the se i es a e ide tified i the S hedule of Be e-fits a d ou e ei e the se i es f o a Net o k De tist. No p io app o al o p io autho izatio f o A gus is e-

ui ed. If ou e ei ed e e ge de tal a e f o a o -Net o k De tist, o-pa e ts ide tified i the S hedule of Be efits do ot appl . Rathe , ou ill e o ligated to pa the ates ha ged the o -Net o k De tist.

Does A gus ha dle oo di atio of e efits?

No A gus does ot ha dle oo di atio of e efits fo Maste Pla e e s.

Defi itio s Appli a le to the Maste Pla : Co‐pa e t ea s the pa e t o ed the Me e to the Net o k De tist fo the Co e ed Se i e e -

de ed. Co e ed Se i es ea s the se i es a d t eat e t that a e pa a le o a aila le u de the Maste Pla . De tal E e ge ea s the sudde a d u e pe ted o set of a a ute o ditio i ol i g se e e pai , e-

ui i g i ediate de tal a e fo te po a elief of pai a d suffe i g. E a ples of De tal E e ge ies i -lude a tootha he a d o al t au a.

Me e ea s a i di idual e titled to e ei e Co e ed Se i es u de the Me e Pla . Net o k De tist ea s a de tal a e p a titio e o fa ilit ho/ hi h has e te ed i to a ag ee e t ith

A gus fo the p o isio of Co e ed Se i es u de the Maste Pla . P e iu ea s the pe iodi o thl o a ual pa e t o ed to A gus i e ha ge fo pa ti ipatio i a d

o e age u de the Maste Pla . S hedule of Be efits efe s to the s hedule set fo th elo hi h outli es a the Co e ed Se i es

la eled u de the Maste Pla , the appli a le Co-pa e t pa a le the Me e to the Net o k De tist fo ea h Co e ed Se i e, a d the othe te s a d o ditio s appli a le to the Maste Pla .



Me e Co e age

You o e age u de the Maste Pla ill e effe ti e o the fi st da of the o th follo i g ou fi st p e i-u pa e t. Me e ship fee s , pa e ts a d othe te s a d o ditio s of the Pla a e ha ged. A gus ag ees to otif Me e s, i iti g, of the atu e a d e te t of su h ha ges fo t -fi e da s p io to the effe -ti e date of su h ha ges.

Mo thl P e iu . I e ha ge fo ou pa ti ipatio i the Maste Pla , ou ill e e ui ed to pa a o thl p e i-u fee to A gus as follo s:

Due Date. You o thl P e iu is due o late tha the fiftee th th da of ea h o th. Ho e e , ou ill ha e a te da g a e pe iod to ake ou pa e t. This ea s that if a e ui ed p e iu is ot paid to A gus o o e-fo e the date it is due, it a e paid du i g the g a e pe iod a d ou o e age ill sta i fo e du i g that ti e.

O goi g Ca e. If A gus te i ates ou pa ti ipatio i the Maste Pla i a o da e ith the te s set fo th i the E -oll e t Appli atio , su h te i atio ill e ithout p ejudi e to a o ti uous loss that ega hile ou o e age as i fo e. I the ase of a su h o ti uous loss, A gus shall o ti ue to p o ide its se i es he eu de , a d shall

e ui e the Net o k De tists to o ti ue to p o ide thei se i es u til the ea lie of a the date the spe ifi t eat e t o p o edu e has ee o pleted, o i et da s f o the te i atio date of ou pa ti ipatio . Ho e e , this

ill o l e the ase if ou o ti ue to pa the o thl p e iu o ed du i g su h ti e.

Eligi ilit E oll e t. I additio to ou self, ou a e oll ou eligi le fa il e e s i the Maste Pla . You eligi le fa il e e s i lude ou spouse o do esti pa t e a d ou atu al o a d adopted hild e i ludi g a hild e pla ed ith ou fo adoptio ho ha e ot et attai ed age t e t -si o a e su sta tiall depe de t o ou fo suppo t a d ai te a e a d i apa le of sustai i g e plo e t easo of e tal o ph si al disa ilit .

E oll e t of Ne l Eligi le Pe so s. You a e oll ou e o hild i the Maste Pla f o the o e t of i th, adoptio , o pla e e t fo adoptio of su h hild. You a also e oll a e l eligi le fa il e e i the Maste Pla . Ho e e , ou ust do so ithi thi t da s of the date he/she eets the eligi ilit e ui e e ts of the Maste Pla .

Notifi atio O ligatio . You ust otif A gus if ou a ui e a e fa il e e o if a fa il e e loses eligi ilit to pa ti ipate i the Maste Pla . You ust p o ide this i fo atio ithi fiftee da s of the date of the appli a le ha ge.

P i a . A gus ag ees to o pl ith all fede al a d state la s that p ote t the p i a a d se u it of pe so al health i fo atio .

MONTHLY* ANNUAL

I di idual $ . $ .

I di idual + $ . $ .

Fa il $ . $ .

* For o thly pre iu s, your a ou t ill e de ited or harged the o thly pre iu stated plus a $1 o thly ser i e harge.



Possi le Auto ati Te i atio . You pa ti ipatio i the Maste Pla ill auto ati all te i ate if the Flo ida Offi e of I su a e Regulatio issues a o de e ui i g a ellatio of ou pa ti ipatio , a d su h o de e o es fi al a d o -appeala le.

A gus’ Ca ellatio Rights . A gus is e titled to a el ou pa ti ipatio o the pa ti ipatio of a of ou fa il e -e s , upo fo t -fi e da s’ itte oti e if:

a You eha io is dis upti e, u ul , a usi e, u la ful, f audule t, o u oope ati e to the e te t that ou o ti -ui g pa ti ipatio se iousl i pai s A gus’ a ilit to p o ide se i es to othe Me e s

You e gage i f aud o ake a ate ial is ep ese tatio i appl i g fo o p ese ti g a lai fo e efits

You isuse do u e ts p o ided as e ide e of e efits a aila le u de the Maste Pla , o

d You p o ide A gus ith i o e t o i o plete i fo atio fo the pu poses of f audule tl o tai i g se i es o e efits.

P io to a elli g ou pa ti ipatio as p o ided a o e, A gus ust ake a effo t to esol e the p o le th ough its g ie a e p o edu es, a d ust dete i e that ou eha io is ot due to use of the se i es p o ided o e tal ill ess.

E used Pe fo a e. A gus shall ot e lia le to ou o a othe Me e fo a failu e o dela i pe fo i g its o ligatio s, hi h dela o failu e is due, i hole o i pa t, di e tl o i di e tl , to a o ti ge , dela , failu e, o ause of a atu e e o d the easo a le o t ol of A gus, i ludi g, ithout li itatio , fi e, e plosio , ea th uake,

sto , flood o othe eathe - elated e e t o a a t of God; u a aila ilit of e essa utilities, o po e ts, o a ate ials; st ike, lo kout o a ti ities of a o i atio of o k e o othe la o diffi ulties; a , a t of te o is , i su -

e tio o iot; appli atio of a la , a t, o de , e po t o t ol egulatio , p o la atio , de ee, egulatio , o di-a e, o i st u tio s of go e e t o othe pu li autho ities, o a judg e t o de ee of a ou t of o pete t ju-isdi tio ot a isi g out of a ea h of its o ligatio s he eu de . I the e e t of the happe i g of su h a ause, A gus

shall p o ide ou ith p o pt, itte oti e stati g the pe iod of ti e the failu e to pe fo is e pe ted to o ti ue, a d shall esu e its pe fo a e as soo as easo a l possi le.

No Right of Assig e t. Neithe ou o a of ou fa il e e s shall ha e the ight to assig , delegate, o othe ise t a sfe a o all of ou ights a d/o o ligatio s elati g to the Maste Pla to a thi d pa t .

E ti e Ag ee e t. The E oll e t Appli atio , Ce tifi ate, a d Me e Guide set fo th the e ti e ag ee e t et ee ou a d A gus elati g to the Maste Pla . U less othe ise stated, the te s of ou ag ee e t a ot e a e ded o odified u less the a e d e t o odifi atio is i iti g a d is sig ed ou a d A gus. As stated a o e, A gus ill

otif Me e s, i iti g, of the atu e a d e te t of a a e d e t o odifi atio fo t -fi e da s p io to the effe ti e date of su h ha ges.

Wai e . No ai e of a ea h o o ditio of ou ag ee e t ith A gus shall e o side ed a ai e of a su se-ue t ea h o o ditio , hethe of like o diffe e t atu e.

Go e i g La . You ag ee e t ith A gus ill e go e ed the la s of the State of Flo ida.

Ju isdi tio a d Ve ue; Fees. A it atio is olu ta a d shall e o du ted pu sua t to Flo ida Statutes Chapte . A a it atio , ediatio o a tio to e fo e o i te p et the ights of the pa ties ith espe t to the Maste Pla shall

e hea d solel a d e lusi el i Hills o ough Cou t , Flo ida. You he e o se t, o ehalf of ou self a d ou fa il e e s, to su h e lusi e ju isdi tio a d e ue. You ill e espo si le fo pa i g ou o legal fees i a su h e -

lusi e ju isdi tio a d e ue. You ill e espo si le fo pa i g ou o legal fees i a su h a it atio , ediatio o a tio .



S hedule of Be efits: The elo o-pa e ts o tai ed i this fee s hedule a e alid o l he t eat e t is p o ided a Pa ti ipati g Ge e al De tist. If the se i es of a Pa ti ipati g Spe ialist a e e o e ded a d a aila le, the the elo o-pa e ts DO NOT appl a d the e e 's ha ge ill e the Pa ti ipati g Spe ialist's usual a d usto a fee, less a dis ou t of %. If a se i e is ot listed elo , it a e a aila le at the

Pa ti ipati g De tal P o ide 's Usual a d Custo a Fee, less a dis ou t of %. Ea h offi e isit i ludes all fees fo ste ilizatio a d i fe tio o -t ol.

Procedure Code Descriptio Co-Pay e t

DIAGNOSTICS

D Pe iodi O al E aluatio - Esta lished Patie t

D Li ited O al E aluatio - P o le Fo used

D O al E aluatio fo a Patie t U de Th ee Yea s of Age a d Cou seli g ith P i a Ca egi e

D Co p ehe si e O al E a

D Detailed a d E te si e O al E aluatio - P o le Fo used, Repo t

D Co p ehe si e Pe iodo tal E aluatio

D X- a s I t ao al - Co plete Se ies, I ludi g Bite i gs O e Pe Yea s

D X- a s I t ao al - Pe iapi al - Fi st Fil

D X- a s I t ao al - Pe iapi al - Ea h Additio al Fil

D X- a s I t ao al - O lusal Fil

D E t ao al - Fi st Fil

D E t ao al - Ea h Additio al Fil

D X- a s Bite i g - Si gle Fil O e Pe Yea

D X- a s Bite i gs - T o Fil s O e Pe Yea

D X- a s Bite i gs - T o Fil s Additio al Pai Pe Yea

D X- a s Bite i gs - Th ee Fil s O e Pe Yea

D X- a s Bite i gs - Th ee Fil s Additio al Set Pe Yea

D X- a s Bite i gs - Fou Fil s O e Pe Yea

D X- a s Bite i gs - Fou Fil s Additio al Set Pe Yea

D Ve ti al Bite i gs - to Fil s

D Poste io - A te io o Late al Skull a d Fa ial Bo e Su e Fil

D Te po o a di ula Joi t Fil

D To og aphi Su e

D X- a s Pa o a i Fil O e Pe Th ee Yea s

D X- a s Pa o a i Fil Ea h Additio al

D Cephalo et i Fil

D O al/Fa ial Photog aphi I ages

D Colle tio of Mi oo ga is s fo Cultu e a d Se siti it

D Ca ies Sus epti ilit Tests

D Pulp Vitalit Testi g

D Diag osti Casts

D Offi e Visit - Pe Visit I ludi g All Fees fo Ste ilizatio a d/o I fe tio Co t ol

PREVENTIVE

D P oph la is - Adult T i e Pe Yea , O e Pe Si Mo ths

D P oph la is - Adult Ea h Additio al Note: Routi e Clea i g Does Not Appl to Patie ts Diag osed ith Pe iodo tal Disease

D P oph la is - Child T i e a Yea , O e Pe Si Mo ths

D P oph la is - Child Ea h Additio al

D Topi al Appli atio of Fluo ide E ludi g P oph la is - Child

D Topi al Appli atio of Fluo ide E ludi g P oph la is - Adult

D Topi al Fluo ide Va ish; The apeuti Appli atio fo Mode ate to High Ca ies Risk Patie ts

D Nut itio al Cou seli g fo Co t ol of De tal Disease

D To a o Cou seli g

D O al H gie e I st u tio

D Seala t - Pe Tooth

D Spa e Mai tai e - Fi ed - U ilate al**




D Spa e Mai tai e - Fi ed - Bilate al**

D Spa e Mai tai e - Re o a le - U ilate al**

D Spa e Mai tai e - Re o a le - Bilate al**

D Re e e tatio of Spa e Mai tai e

D Re o al of Fi ed Spa e Mai tai e

RESTORATIVE

D A alga - O e Su fa e, P i a o Pe a e t

D A alga - T o Su fa es, P i a o Pe a e t

D A alga - Th ee Su fa es, P i a o Pe a e t

D A alga - Fou o Mo e Su fa es, P i a o Pe a e t

D Resi - O e Su fa e, A te io

D Resi - T o Su fa es, A te io

D Resi - Th ee Su fa es, A te io

D Resi - Fou o Mo e Su fa es, A te io o I ol i g I isal A gle

D Resi -Based Co posite C o , A te io

D Resi -Based Co posite, O e Su fa e, Poste io

D Resi -Based Co posite, T o Su fa es, Poste io

D Resi -Based Co posite, Th ee Su fa es, Poste io

D Resi -Based Co posite, Fou Su fa es, Poste io

D Gold Foil - O e Su fa e

D Gold Foil - T o Su fa es

D Gold Foil - Th ee Su fa es

D I la - Metalli - O e Su fa e

D I la - Metalli - T o Su fa es

D I la - Metalli - Th ee o Mo e Su fa es

D O la - Metalli - Th ee Su fa es

D O la - Metalli - Fou o Mo e Su fa es

D I la - Po elai /Ce a i - O e Su fa e

D I la - Po elai /Ce a i - T o Su fa es

D I la - Po elai /Ce a i - Th ee o Mo e Su fa e

D O la - Po elai /Ce a i - T o Su fa es

D O la - Po elai /Ce a i - Th ee Su fa es

D O la - Po elai /Ce a i - Fou o Mo e Su fa es

D I la - Resi -Based Co posite - O e Su fa e

D I la - Resi -Based Co posite - T o Su fa es

D I la - Resi -Based Co posite - Th ee o Mo e Su fa es

D O la - Resi -Based Co posite - T o Su fa es

D O la - Resi -Based Co posite - Th ee Su fa es

D O la - Resi -Based Co posite - Fou o Mo e Su fa es

D C o - Resi -Based Co posite I di e t **

D C o - Resi ith High No le Metal**

D C o - Resi ith P edo i a tl Base Metal**

D C o - Resi ith No le Metal**

D C o Po elai /Ce a i Su st ate**

D C o Po elai Fused to High No le Metal**

D C o Po elai Fused to P edo i atel Base Metal**

D C o Po elai Fused to No le Metal**

D C o - / Cast High No le Metal**

D C o - / Cast P edo i a tl Base Metal**



* De otes La Fees are i luded


D C o - / Cast No le Metal**

D C o - / Po elai /Ce a i **

D C o - Full Cast High No le Metal**

D C o - Full Cast P edo i atel Base Metal**

D C o - Full Cast No le Metal**

D Re e e t I la , O la , o Pa tial Co e age Resto atio

D Re e e t Cast o P efa i ated Post a d Co e

D Re e e t C o

D P efa i ated Stai less Steel C o - P i a

D P efa i ated Stai less Steel C o - Pe a e t

D P efa i ated Resi C o

D P efa i ated Stai less Steel C o ith Resi Wi do

D P ote ti e Resto atio Sedati e Filli g

D Co e Buildup, I ludi g A Pi s

D Pi Rete tio - Pe Tooth, i Additio to Resto atio

D Post a d Co e i Additio to C o , I di e tl Fa i ated

D Ea h Additio al I di e tl Fa i ated Post - Sa e Tooth

D P efa i ated Post a d Co e i Additio to C o

D Post Re o al Not i Co ju tio ith E dodo ti The ap

D Ea h Additio al P efa i ated Post - Sa e Tooth

D La ial Ve ee Resi La i ate - Chai side

D La ial Ve ee Resi La i ate - La o ato **

D La ial Ve ee Po elai La i ate - La o ato **

D Te po a C o F a tu ed Tooth, if Sepa ate f o C o

ENDODONTICS

D Pulp Cap, Di e t E ludi g Fi al Resto atio

D Pulp Cap, I di e t E ludi g Fi al Resto atio

D The apeuti Pulpoto

D Pulpal De ide e t, P i a a d Pe a e t Teeth

D Pulpal The ap Reso a le Filli g - A te io , P i a Tooth E ludi g Fi al Resto atio

D Pulpal The ap Reso a le Filli g - Poste io , P i a Tooth E ludi g Fi al Resto atio

D Root Ca al - A te io - Pe Tooth

D Root Ca al - Bi uspid - Pe Tooth

D Root Ca al - Mola - Pe Tooth

D I o plete E dodo ti The ap ; I ope a le, U esto a le o F a tu ed Tooth

D Ret eat e t of P e ious Root Ca al The ap - A te io

D Ret eat e t of P e ious Root Ca al The ap - Bi uspid

D Ret eat e t of P e ious Root Ca al The ap - Mola

D Ape ifi atio /Re al ifi atio - I itial Visit

D

Ape ifi atio /Re al ifi atio - I te i Medi atio Repla e e t Api al Closu e/Cal ifi Repai of Pe fo atio s, Root Reso p-tio , et .

D

Ape ifi atio /Re al ifi atio - Fi al Visit I ludes Co pleted Root Ca al The ap - Api al Closu e/Cal ifi Repai of Pe fo a-tio s, Root Reso ptio , et .

D Api oe to /Pe i adi ula Su ge - A te io

D Api oe to /Pe i adi ula Su ge - Bi uspid, Fi st Root

D Api oe to /Pe i adi ula Su ge - Mola , Fi st Root

D Api oe to /Pe i adi ula Su ge - Additio al Roots

D Ret og ade Filli g

D Root A putatio - Pe Root

D E dodo ti E dosseous I pla t

D I te tio al Rei pla tatio I ludi g Ne essa Spli ti g

D Su gi al P o edu e fo Isolatio of Tooth ith Ru e Da

D He ise tio - I ludi g Root Re o al E ludi g Root Ca al The ap

D Ca al P epa atio a d Fitti g of P efo ed Post



PERIODONTICS

D Gi gi e to o Gi gi oplast , Pe Quad a t o Mo e Teeth

D Gi gi e to o Gi gi oplast , Pe Quad a t to Teeth

D Gi gi al Flap P o edu e, I ludi g Root Pla i g - o Mo e Teeth Pe Quad a t

D Gi gi al Flap P o edu e, I ludi g Root Pla i g - to Teeth Pe Quad a t

D Api all Positio ed Flap

D Cli i al C o Le gthe i g - Ha d Tissue

D Osseous Su ge I ludi g Flap E t a d Closu e - Pe Quad a t o Mo e Teeth

D Osseous Su ge I ludi g Flap E t a d Closu e - Pe Quad a t to Teeth

D Bo e Repla e e t G aft - Fi st Site i Quad a t

D Bo e Repla e e t G aft - Ea h Additio al Site i Quad a t

D Guided Tissue Rege e atio - Reso a le Ba ie , Pe Site

D Guided Tissue Rege e atio - No eso a le Ba ie , Pe Site I ludes Me a e Re o al

D Pedi le Soft Tissue G aft P o edu e

D F ee Soft Tissue G aft P o edu e I ludi g Do o Site Su ge

D

Distal o P o i al Wedge P o edu e Whe Not Pe fo ed i Co ju tio ith Su gi al P o edu es i the Sa e A a-to i al A ea

D P o isio al Spli ti g - I t a o o al

D P o isio al Spli ti g - E t a o o al

D Pe iodo tal S ali g a d Root Pla i g - Pe Quad a t o Mo e Teeth

D Pe iodo tal S ali g a d Root Pla i g - Pe Quad a t to Teeth

D Full Mouth De ide e t to E a le Co p ehe si e E aluatio & Diag osis

D Pe iodo tal Mai te a e P o edu es - Follo i g A ti e Su ge i a Mo th Pe iod

D U s heduled D essi g Cha ge So eo e Othe tha T eati g De tist

PROSTHODONTICS

D Co plete Uppe De tu e**

D Co plete Lo e De tu e**

D I ediate Uppe De tu e**

D I ediate Lo e De tu e**

D Pa tial Uppe - Resi Base ith Clasps/Rests & Teeth **

D Pa tial Lo e - Resi Base ith Clasps/Rests & Teeth **

D Uppe Pa tial - Cast Metal Base ith Resi Saddles ith Clasps/Rests & Teeth **

D Lo e Pa tial - Cast Metal Base ith Resi Saddles ith Clasps/Rests & Teeth **

D Re o a le U ilate al Pa tial De tu e - O e Pie e Cast Metal I ludi g Clasps a d Teeth **

D Adjust Co plete De tu e - Uppe

D Adjust Co plete De tu e - Lo e

D Adjust Pa tial De tu e - Uppe

D Adjust Pa tial De tu e - Lo e

D Repai B oke Co plete De tu e Base**

D Repla e Missi g o B oke Teeth**

D Repai Resi De tu e Base**

D Repai Cast F a e o k**

D Repai o Repla e B oke Clasp**

D Repla e B oke Teeth - Pe Tooth**

D Add Tooth to E isti g Pa tial De tu e**

D Add Clasp to E isti g Pa tial De tu e**

D Re ase Co plete Ma illa De tu e**

D Re ase Co plete Ma di ula De tu e**

D Re ase Ma illa Pa tial De tu e**

D Re ase Ma di ula Pa tial De tu e**

D Chai side Reli e Co plete Uppe De tu e




D Chai side Reli e Co plete Lo e De tu e

D Chai side Reli e Uppe Pa tial

D Chai side Reli e Lo e Pa tial

D La o ato Reli e Co plete Uppe De tu e**

D La o ato Reli e Co plete Lo e De tu e**

D La o ato Reli e Uppe Pa tial**

D La o ato Reli e Lo e Pa tial**

D I te i Co plete De tu e Ma illa

D I te i Co plete De tu e Ma di ula

D I te i Pa tial De tu e Ma illa

D I te i Pa tial De tu e Ma di ula

D Tissue Co ditio i g Ma illa

D Tissue Co ditio i g Ma di ula

D O e de tu e o plete**

D O e de tu e pa tial**

D Fluo ide Gel Ca ie

D Co issu e Spli t ,

PROSTHODONTICS, FIXED

D Su gi al Pla e e t of I pla t Bod : E dosteal I pla t ,

D Su gi al Pla e e t: Eposteal I pla t ,

D Su gi al Pla e e t: T a sosteal I pla t ,

D De tal I pla t Suppo ted Co e ti g Ba

D

I pla t Mai te a e P o edu es, I ludi g Re o al of P osthesis, Clea si g of P osthesis a d A ut e ts a d Rei se tio of P osthesis

D Po ti - Cast High No le Metal **

D Po ti - Cast P edo i a tl Base Metal**

D Po ti - Cast No le Metal**

D Po ti - Tita iu **

D Po ti - Po elai Fused to High No le Metal**

D Po ti - Po elai Fused to P edo i a tl Base Metal**

D Po ti - Po elai Fused to No le Metal**

D Po ti - Resi ith High No le Metal**

D Po ti - Resi ith P edo i a tl Base Metal**

D Po ti - Resi ith No le Metal**

D Cast Metal Retai e fo A id Et h B idge**

D C o - Resi ith High No le Metal **

D C o - Resi ith P edo i a tl Base Metal**

D C o - Resi ith No le Metal**

D C o - Po elai Fused to High No le Metal**

D C o - Po elai Fused to Base Metal**

D C o - Po elai Fused to No le Metal**

D C o - / Cast High No le Metal**

D C o - / Cast P edo i a tl Base Metal**

D C o - / Cast Fused to No le Metal**

D C o - / Po elai /Ce a i **

D C o - Full Cast High No le Metal**

D C o - Full Cast P edo i atel Base Metal**

D C o - Full Cast No le Metal**

D Co e to Ba

D Re e e t B idge

D St ess B eake **




D P e isio Atta h e t**

D Post a d Co e i Additio to Fi ed Pa tial De tu e Retai e , I di e tl Fa i ated

D P efa i ated Post a d Co e i Additio to Fi ed Pa tial De tu e Retai e

D Co e Build Up fo Retai e , I ludi g A Pi s

D Copi g - Metal

D Ea h Additio al I di e tl Fa i ated Post - Sa e Tooth

D Ea h Additio al P efa i ated Post - Sa e Tooth

ORAL SURGERY

D E t a tio , Co o al Re a ts - De iduous Tooth

D E t a tio - E upted Tooth o E posed Root E aluatio &/o Fo eps Re o al

D Su gi al Re o al of E upted Teeth

D Re o al of I pa ted Tooth - Soft Tissue

D Re o al of I pa ted Tooth - Pa tiall Bo

D Re o al of I pa ted Tooth - Co pletel Bo

D Re o al of I pa ted Tooth - Co pletel Bo , ith U usual Su gi al Co pli atio s

D Su gi al Re o al of Residual Tooth Roots

D O a t al Fistula Closu e

D Tooth Rei pla tatio a d/o Sta ilizatio of A ide tall E ulsed o Displa ed Tooth

D Tooth T a spla tatio I ludes Rei pla tatio f o O e Site to A othe a d Spli ti g a d/o Sta ilizatio

D Su gi al A ess of a U e upted Tooth

D Biops of O al Tissue - Ha d

D Biops of O al Tissue - Soft

D Su gi al Repositio i g of Teeth

D Al eoplast i Co ju tio ith E t a tio s - Fou o Mo e Teeth o Tooth Spa es Pe Quad a t

D Al eoloplast i Co ju tio ith E t a tio s - O e to Th ee Teeth o Tooth Spa es, Pe Quad a t

D Al eoplast Not i Co ju tio ith E t a tio s - Fou o Mo e Teeth o Tooth Spa es Pe Quad a t

D Al eoloplast Not i Co ju tio ith E t a tio s - O e to Th ee Teeth o Tooth Spa es Pe Quad a t

D Vesti uloplast - Ridge E te sio Se o da Epithelial

D Vesti uloplast - Ridge E te sio I ludi g Soft Tissue G afts, Mus le Reatta h e t, Re isio of Soft ,

D E isio of Be ig Lesio up to .

D E isio of Be ig Lesio G eate tha .

D E isio of Be ig Lesio , Co pli ated

D E isio of Malig a t Tu o - Lesio Dia ete up to .

D E isio of Malig a t Tu o - Lesio Dia ete G eate tha . ,

D Re o al of Be ig Odo toge i C st o Tu o -Lesio Dia ete up to .

D Re o al of Be ig Odo toge i C st o Tu o -Lesio Dia ete G eate tha .

D Re o al of Be ig No odo toge i C st o Tu o -Lesio Dia ete up to .

D Re o al of Be ig No odo toge i C st o Tu o -Lesio Dia ete G eate tha .

D Dest u tio of Lesio s Ph si al o Che i al Method, Repo t

D Re o al of Late al E ostosis Ma illa o Ma di le

D Re o al of To us Palati us

D Re o al of To us Ma di ula is

D I isio a d D ai age of A s ess-I t ao al Soft Tissue

D I isio a d D ai age of A s ess - I t ao al Soft Tissue - Co pli ated I ludes D ai age of Multiple Fas ial Spa es

D I isio a d D ai age of A s ess-E t ao al Soft Tissue

D I isio a d D ai age of A s ess-E t ao al Soft Tissue - Co pli ated I ludes D ai age of Multiple Fas ial Spa es

D Re o al of Fo eig Bod f o Mu osa, Ski , o Su uta eous Al eola Tissue

D Re o al of Rea tio -P odu i g Fo eig Bodies, Mus uloskeletal S ste

D Pa tial Oste to /Se uest e to of Re o al of No -Vital Bo e




D O lusal O thoti De i e, Repo t

D Osteoplast - Fo O thog athi Defo ities

D Osseous, Osteope iosteal, o Ca tilage G aft of the Ma di le o Ma illa - Autoge ous o No autoge ous, Repo t

D F e ule to

D F e uloplast

D E isio of H pe plasti Tissue Pe A h

D E isio of Pe i o o al Gi gi a

D Closu e of Sali a Fistula ,

ORTHODONTICS

D Li ited O thodo ti T eat e t of the P i a De titio

D Li ited O thodo ti T eat e t of the T a sitio al De titio

D Li ited O thodo ti T eat e t of the Adoles e t De titio

D Li ited O thodo ti T eat e t of the Adult De titio

D Co p ehe si e O thodo ti T eat e t of the T a sitio al De titio

D Co p ehe si e O thodo ti T eat e t of the Adoles e t De titio

D Co p ehe si e O thodo ti T eat e t of the Adult De titio

D P e-O thodo ti T eat e t Visit

D Pe iodi O thodo ti T eat e t Visit As Pa t of Co t a t

D O thodo ti Rete tio Re o al of Applia es, Co st u tio a d Pla e e t of Retai e s

ADJUNCTIVE GENERAL SERVICES

D Palliati e E e ge T eat e t of De tal Pai Mi o P o edu e

D Fi ed Pa tial De tu e Se tio i g

D Lo al A esthesia Not i Co ju tio ith Ope ati e o Su gi al P o edu es

D Regio al Blo k A esthesia

D T ige i al Di isio Blo k A esthesia

D Lo al A esthesia

D Deep Sedatio /Ge e al A esthesia - Fi st Mi utes

D Deep Sedatio /Ge e al A esthesia - Ea h Additio al Mi utes

D A algesia - A iol sis, I halatio of Nit ous O ide

D I t a e ous Co s ious Sedatio /A algesia - Fi st Mi utes

D I t a e ous Co s ious Sedatio /A algesia - Ea h Additio al Mi utes

D No -I t a e ous Co s ious Sedatio

D Co sultatio - Diag osti Se i e P o ided De tist o Ph si ia Othe Tha Re uesti g De tist o Ph si ia

D House/E te ded Ca e Fa ilit Call

D Hospital Call

D Offi e Visit fo O se atio Du i g Regula l S heduled Hou s

D Offi e Visit - Afte Regula l S heduled Hou s

D Case P ese tatio , Detailed a d E te si e T eat e t Pla i g

D The apeuti Pa e te al D ug, Si gle Ad i ist atio

D The apeuti Pa e te al D ugs, T o o Mo e Ad i ist atio s, Diffe e t Medi atio s

D Medi i al Appli atio /I igatio Pe Visit

D Appli atio of Dese sitizi g Medi a e ts

D Fa i atio of Athleti Mouthgua d

D O lusio A al sis - Mou ted Case

D O lusio Adjust e t - Li ited

D O lusio Adjust e t - Co plete

D E a el Mi oa asio

D E te al Blea hi g - Pe A h

D E te al Blea hi g - Pe Tooth

D I te al Blea hi g - Pe A h

D B oke Appoi t e t Less Tha Hou Noti e - Pe Mi ute U it - Ma $


**Me e s a e espo si le fo additio al la fees fo these se i es. La fees shall ot e eed $ . pe p o edu e ode, e ludi g p e ious a d se i-p e ious etal.



Li itatio s & E lusio s

EXCLUSIONS: . Se i es hi h, i the opi io of the pa ti ipati g Ge e al De tist o Spe ialist, a e ot e essa fo the patie t's de tal health. . Cos eti o e pe i e tal de tal se i es, a d/o p o edu es ot ge e all pe fo ed i a Ge e al De tist offi e. . Cost of hospitalizatio a d/o pha a euti als. . A se i es pe fo ed a o -pa ti ipati g Ge e al De tist o o -pa ti ipati g Spe ialist. . Se i es that a ot e pe fo ed e ause of the ge e al health of the patie t. . T eat e t hi h, i the opi io of the pa ti ipati g Ge e al De tist, ust e pe fo ed a o -pa ti ipati g Spe ialist. . Se i es hi h a e ot o siste t ith the usual a d usto a se i es p o ided the Pa ti ipati g Ge e al De tist o Spe ialist. . A de tal t eat e t sta ted p io to the e e 's effe ti e date. . Se i es fo i ju ies a d/o o ditio s hi h a e paid o pa a le u de Wo ke 's Co pe satio o E plo e Lia ilit La s.

. T eat e t fo sts, eoplas s a d alig a ies.

. Se i es p o ided ithout ost to the Su s i e the go e e t o a age the eof, o a u i ipalit , ou t a d othe su di isio s.

. The ost of p e ious etal used i a fo of de tal e efits.

. A p o edu e ot spe ifi all listed as a o e ed e efit i the S hedule of Be efits.

. Cost of de tal a e o e ed u de a auto o ile, edi al o o-fault o si ila t pe i su a e.

. Fi ed idge o k is ot o e ed.

. Seala ts applied to a teeth a e ot o e ed.

Right to T a sfe A o g Net o k De tists: A gus has the ight to t a sfe a Me e to a othe Net o k De tist fo a o e of the follo i g easo s:

. If the Me e ’s hose Net o k De tist is o lo ge pa ti ipati g i A gus’ Net o k;

. If the Me e ’s hose Net o k De tist is dete i ed A gus to e u a le to effe ti el e de se i es to the Me e ; o

. Whe e easo a le effo ts to esta lish a satisfa to de tist/patie t elatio ship et ee the Me e a d the Me e ’s hose Net o k De tist ha e failed.



Me e Rights & Respo si ilities

POLICY: Flo ida la e ui es that ou health a e p o ide o health a e fa ilit e og ize ou ights hile ou a e e ei i g

edi al a e a d that ou espe t the health a e p o ide ’s o health a e fa ilit ’s ight to e pe t e tai eha io o the pa t of patie ts. You a e uest a op of the full te t of this la f o ou health a e p o ide o health a e fa ilit .

PROCEDURE: A patie t has the ight to:

. e t eated ith ou tes a d espe t, ith app e iatio of his o he i di idual dig it , a d ith p ote tio of his o he eed fo p i a .

. a p o pt a d easo a le espo se to uestio s a d e uests.

. k o ho is p o idi g health a e se i es a d ho is espo si le fo his o he a e.

. k o hat patie t suppo t se i es a e a aila le, i ludi g hethe a i te p ete is a aila le if he o she does ot speak E glish.

. k o hat ules a d egulatio s appl to his o he o du t.

. e gi e the health a e p o ide i fo atio o e i g diag osis, pla ed ou se of t eat e t, alte ati es, isks, a d p og osis.

. efuse a t eat e t, e ept as othe ise p o ided la .

. e gi e , upo e uest, full i fo atio a d e essa ou seli g o the a aila ilit of k o fi a ial esou es fo his o he a e.

. k o , upo e uest a d i ad a e of t eat e t, hethe the health a e p o ide o fa ilit a epts the patie t’s pla e efit o e age.

. e ei e, upo e uest, p io to t eat e t, a easo a le esti ate of ha ges fo health a e se i es.

. e ei e a op of a easo a l lea a d u de sta da le, ite ized ill a d, upo e uest, to ha e the ha ges e -plai ed.

. i pa tial a ess to t eat e t o a o odatio s, ega dless of a e, atio al o igi , eligio , ha di ap, o sou e of pa e t.

. t eat e t fo a e e ge o ditio that ill dete io ate f o failu e to p o ide t eat e t.

. k o if t eat e t is fo pu poses of e pe i e tal esea h a d to gi e his o he o se t o efusal to pa ti ipate i su h e pe i e tal esea h.

. e p ess g ie a es ega di g a iolatio of his o he ights, as stated i Flo ida la , th ough the g ie a e p o e-du e of the p o ide o fa ilit that se ed hi o he a d to the app op iate state li e si g age .

. to pa ti ipate ith the p o ide i aki g de isio s a out the health a e he o she e ei es a d p o ide i put i to pla ed t eat e t.

. e ei e i fo atio a out A gus, its se i es, p o ide s a d e e /patie ts' ights a d espo si ilities.

. pa ti ipate ith the p o ide i aki g de isio s a out his o he health a e.

. ha e a a did dis ussio a out app op iate o edi all e essa t eat e t optio s fo ou health o ditio s, e-ga dless of ost o e efits.

. oi e o plai ts o appeals a out A gus o the a e it p o ides.

. ake e o e datio s a out A gus' e e ights a d espo si ilities poli ies.

. e ei e i fo atio a out ad a e di e ti es, p o ide ’s ede tials a d a se e of alp a ti e o e age.

. ha ge p o ide s if othe p o ide s a e a aila le.



Me e Rights & Respo si ilities

A patie t has the espo si ilit : . to p o ide to A gus a d its p o ide s, to the est of his o he k o ledge, a u ate a d o plete i fo atio a out

p ese t o plai ts, past ill esses, hospitalizatio s, edi atio s, a d othe atte s elati g to his o he health. . to epo t u e pe ted ha ges i his o he o ditio to the p o ide . . to epo t to the p o ide hethe he o she o p ehe ds a o te plated ou se of a tio a d hat is e pe ted of

hi o he . . to u de sta d his o he health p o le s a d pa ti ipate i de elopi g utuall ag eed-upo t eat e t goals to the

deg ee possi le. . to follo the t eat e t pla e o e ded the p o ide . . to keep appoi t e ts a d, he he o she is u a le to do so fo a easo , ill otif the p o ide o fa ilit . . fo his o he a tio s if he o she efuses t eat e t o does ot follo the p o ide 's i st u tio s. . to assu e the fi a ial o ligatio s of his o he a e a e fulfilled as p o ptl as possi le. . to follo fa ilit ules a d egulatio s affe ti g patie t a e a d o du t.

. to i fo his o he p o ide a out a li i g ill, edi al po e of atto e , o othe di e ti e that ould affe t his o he a e.

. to p o ide a espo si le adult fo t a spo tatio f o the fa ilit if e ui ed the p o ide i situatio s he e se-datio is ad i iste ed.

P o ide s a e e ui ed to p o ide se i es that a e: . Not dis i i ati g agai st a patie t i a a e i ludi g ut ot li ited to:

a Sou e of pa e t Ra e

Eth i it

d Natio al o igi

e Se

f Se ual o ie tatio

g Age

h Religio

i Pla e of eside e

j Health status

k Me tal o ph si al disa ilit l Clai s e pe ie e

Medi al histo E ide e of i su a ilit

o Ge eti i fo atio . P ese i g patie t dig it a d o se i g the ights of patie ts. . A idi g all ad i ist ati e a d edi al poli ies a d p o edu es esta lished A gus. . P o idi g all se i es i a ultu all o pete t a e a d a o odati g patie ts ith disa ilities. . P o idi g patie ts ith o plete i fo atio o e i g thei diag osis, t eat e t, a d p og osis a d gi i g the

the oppo tu it to pa ti ipate i de isio s i ol i g thei health a e.



Co plai ts a d G ie a es

I fo al G ie a es: A Me e ho has a g ie a e agai st A gus De tal & Visio , I . ADVI fo a atte a isi g f o a Su s i e Ce tifi ate o fo o e ed se i es e de ed he eu de a su it a i fo al o al g ie a e to ADVI. Assista e ith ADVI’s g ie a e p o edu es, i ludi g assista e ith i fo al o al g ie a es, a e o tai ed alli g ADVI’s Me e Se i es Depa t e t at - . O al g ie a es shall e su itted to ADVI’s G ie a e & Appeals De-pa t e t. I fo al o al g ie a es shall e espo ded to as soo as possi le the G ie a e Coo di ato . If the i fo -

al o al g ie a e i ol es a edi al- elated atte o lai , a de tist shall e i ol ed i esol i g said g ie a e. The Me e has the ight to file a fo al itte g ie a e ith ADVI a d to appeal to the Flo ida Depa t e t of Fi a ial Se i es.

Su issio of Fo al G ie a es: A Me e ho has a g ie a e agai st ADVI fo a atte a isi g out of the Ce tifi ate o o e ed se i es e de ed he eu de a su it a fo al itte state e t of the g ie a e to ADVI. Su h itte state e t shall e spe ifi all ide tified as a g ie a e a d shall e su itted to ADVI ithi si t da s f o the date of the o u e e. The

itte g ie a e shall o tai a state e t of a tio e uested the Me e ; the Me e ’s a e, add ess, tele-pho e u e , e e u e ; the a e of the Su s i e ’s Pa ti ipati g Ge e al De tist o Pa ti ipati g Spe ialist; a d the Su s i e ’s sig atu e a d the date. The state e t should e se t to ADVI’s G ie a e Coo di ato at ADVI’s add ess as set fo th he ei . Mo e i fo atio o ADVI’s g ie a e p o edu es a e o tai ed alli g ADVI’s Me -

e Se i es Depa t e t at ADVI’s telepho e u e set fo th a o e.

E pedited G ie a es: ADVI ill o fi e eipt of the Me e ’s e pedited g ie a e, o all , ithi t e t -fou hou s. ADVI ill esol e the e pedited g ie a e ithi se e t -t o hou s a d ill o u i ate the esolutio o all a d i iti g to the Me e .

Respo se to Fo al G ie a es: ADVI ill o fi e eipt of the Me e ’s g ie a e, i iti g, ithi fi e usi ess da s. ADVI ill esol e the g ie -a e a d o u i ate the esolutio , i iti g, ithi thi t da s. The ti ef a e a e e te ded up to thi t

da s if the Me e asks fo a e te sio o the Pla do u e ts that additio al i fo atio is eeded a d the de-la is i the Me e ’s i te est. A g ie a e is ot o side ed fo al u til the Pla e ei es a itte su a f o the Me e .

Appeal of De isio : If the a tio take the Pla is ot satisfa to to the Me e , the Me e a appeal the atte to the Pla ithi thi t da s afte e ei i g oti e of the esolutio . The Me e ’s e uest fo a appeal ust e su itted to the pla i iti g, a d should e di e ted to: A gus De tal & Visio , I ., G ie a e Depa t e t, W. State St., Ta pa, FL . The Pla ill esol e all appeals a d o u i ate the esolutio , i iti g, ithi thi t da s. If the Me e is dissatisfied ith the appeal de isio , the Me e has the ight to appeal to the State of Flo ida Depa t e t of Fi a ial Se i es a d/o the Offi e of I su a e Regulatio of the Fi a ial Se i es Co issio .



Looking for a Dentist?

We make it easy!

Visit us o li e to fi d a A gus De tal & Visio de tal p o ide toda !

. Go to .a gusde tal isio . o

. Cli k o the P o ide Sea h utto i the iddle of the ho e page

. Sele t ou Pla t pe, a d e te ou it a d zip ode

. P ess the Sea h utto a d ou esults ill appea



ARGUS DENTAL & VISION, INC. Toll F ee - - | West State St eet | Ta pa, Flo ida

.a gusde tal isio . o

The Premier Choi e i De tal & Visio Be efits

Questio s?

If ou ha e uestio s o eed fu the assista e, please all A gus Custo e Ca e toll-f ee at - - - .


the premier choie i detal & visio beeits member guide ... · neto k deist ueas a Ç detal ae...

Documents