Document ID: chunk:federal_register_of_legislation:F2024C01114:clause:3_7
Version: federal_register_of_legislation:F2024C01114
Segment Type: clause
Provision Reference: sch 3 cl 7
Character Range: 88159–92573

7                                                           Examples of maximum benefits—general dental, major dental, endodontic and orthodontic
                                                            For each treatment listed in paragraphs (a) to (d) of item 3 (whether or not covered by the policy):
                                                             (a) the following treatments, broken down into the following dental item numbers:
                                                             (i) for general dental:
                                                              (A) "Periodic oral examination"—012; and
                                                              (B) "Scale & clean"—114; and
                                                              (C) "Fluoride treatment"—121; and
                                                              (D) if covered under general dental—"Surgical tooth extraction"—
                                                              322;
                                                             (ii) for major dental treatment:
                                                              (A) if covered under major dental—"Surgical tooth extraction"—
                                                              322; and
                                                              (B) "Full crown veneered"—615;
                                                             (iii) for endodontic treatment—"Filling of one root canal"—417;
                                                             (iv) for orthodontic treatment—"Braces for upper and lower teeth, including
                                                              removal plus fitting of retainer"—881; and
                                                             (b) if the dental item number is covered by the policy—an example of the maximum
                                                             benefit that is payable when an insured person visits a practitioner who is not a
                                                             preferred service provider, expressed using whichever of the following is
                                                             applicable:
                                                             (i) "$[number]", with the bracketed text replaced by the appropriate figure,
                                                              if:
                                                              (A) the benefit is a dollar figure; or
                                                              (B) the insurer pays a benefit that is a percentage of the charge up to
                                                              a dollar limit that is specified for the item separately from an
                                                              annual limit;
                                                             (ii) if the only benefit limit for the item is an annual limit— "[number]% of
                                                              charge", with the bracketed text replaced by the appropriate figure; and
                                                             (c) if the dental item number is not covered by the policy—the statement "n/a".

                                                            For paragraph (b) of this item:
                                                             (d) if:
                                                             (i) the dental item number is provided by orthodontists and general dentists;
                                                              and
                                                             (ii) different benefits are offered for orthodontists and general dentists;
                                                              the lower of:
                                                             (iii) the benefit for the orthodontist; and
                                                             (iv) the benefit for the general dentist;
                                                               must be used; and
                                                             (e) if examples are given for initial and subsequent visits, examples must be for
                                                             individual sessions.