DRC Operational Manual 2013 - MM3 Admin
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DRC Operational Manual
2013
General Providers
OUR CLIENTS
Dental Risk Company is proud to provide its services to the following medical aid schemes and administrators.
RISK MANAGEMENT CLIENTS: CLAIMS ADMINISTRATION AND PRE-AUTHORISATIONS
Discovery Health KeyCare Plus and Access Options and LA Health
Furnmed Compulsary and Continuation Options
Nufawsa Standard and Select Options
Transmed State Plus Own Choice, Private Network and Guardian
Moto Health Classic and Optimum
PRE- AUTHORISATIONS AND CLAIMS VALIDATION CLIENTS
Liberty Medical Scheme Titan Option and Titan Select
Profmed All options
Transmed State Plus Own Choice, Private Network and Guardian
Moto Health Classic and Optimum
PROVIDER NETWORK CONTRACT CLIENTS
CareCross Health (See CareCross website for list of individual Schemes)
Transmed State Plus Own Choice, Private Network and Guardian
Fedhealth Blue Door Option
CALL CENTRE CONTACT DETAILS FOR OUR CLIENTS
Profmed 0860 679 200
CareCross 0860 101 159
Discovery 086 44 55 66
Furnmed (011) 242 9200
Nufawsa 086 163 6840
Liberty 0860 002 163
Transmed State Plus Own Choice 0800 650 010
Transmed Guardian 0800 110 268
Moto Health 0861 000 300
CLAIMS
PROCESSING OF CLAIMS
1. DRC will be responsible for clinical authorisation and validations for the below Schemes, and all claims
must go directly to the Scheme or its administrator for processing:
Profmed: All Options
Liberty Medical Scheme: Titan Options
Discovery Health
Transmed
2. DRC will be responsible for claims processing, validation and authorisations for the below Schemes, and
all claims must be sent directly to DRC.
Nufawsa
Furnmed
Moto Health (Custom and Optimum Options)
2The switching codes below are to be used for the above schemes:
Nufawsa, Furnmed, Moto Health (Custom and Optimum Options) must be submitted to DRC through
the below switches:
HealthBridge HB41
DHSwitch 406P
Mediswitch DRCC0001
ALL OTHER CLAIMS MUST BE SUBMITTED DIRECTLY TO THE RELEVANT SCHEMES
DRC would like to urge all our providers to seriously consider submitting their claims electronically. This is
not only the most reliable mode of submission, but it is also fast and cost effective.
Paper claims must be submitted to DRC, PO Box 7824, Centurion, 0046
OR
emailed to claims@dentalrisk.com
3. CareCross claims for processing must be send to PO Box 4491, Claremont, 7735 or hand delivered via
courier to 10 Mill Street, Newlands, 7700.
Electronic submission must be done to the following destinations: Q-EDI 561P
Mediswitch care0006
CLAIM QUERIES CAN BE SENT TO
Discovery discovery@dentalrisk.com
Profmed profmedqueries@dentalrisk.com
Transmed claims@dentalrisk.com
Nufawsa claims@dentalrisk.com
Furnmed claims@dentalrisk.com
Liberty enquiries@libertyhealth.co.za
Moto Health claims@dentalrisk.com
EDI SUBMISSIONS FOR BOTSWANA MEDICAL AID SOCIETY (BOMAID)
Botswana Medical Aid Society (Bomaid). The switching code is 595.
Bomaid has registered with DH Switch and you can now submit directly to them on code 595.
AUTHORISATIONS
All authorisations are performed via a quotation basis which means you will need to compile a quote of the
work to be done that needs authorising by DRC. Once the pre-authorisation form is completed you can email
it to auth@dentalrisk.com or fax it to 086 687 1285.
CareCross authorisations must be sent via fax to CareCross Health at (021) 673-1811 or email to
dentalmotivations@carecross.co.za
Transmed authorisations must be emailed to transmedauth@dentalrisk.com.
Moto Health authorisations must be emailed to motohealthauth@dentalrisk.com.
Authorisations will be captured and the full authorisation will be emailed back to you. This will stipulate what is
covered (depending on benefit) and what is not covered so that you can discuss the excess payment with the
member before performing the procedure. All pre-authorisations need to be send through 72 hours before
feedback can be expected.
Please note that where medical schemes offer specialised benefits authorisations from DRC indicate that the
procedure is clinically acceptable if benefits are available. Due to the fact that most specialised procedures
are paid from a pooled benefit we cannot guarantee payment in full.
3THIS IS NOT A GUARANTEE OF PAYMENT DUE TO THE BENEFIT BEING SUBJECT
TO A LIMIT MANAGED BY THE SCHEME. FOR BENEFIT CONFIRMATION ON
SPECIALISED BENEFITS, PLEASE CONTACT THE RELEVANT MEDICAL SCHEMES.
Please note that all relevant ICD 10 codes need to be forwarded to DRC along with the following:
Scheme Name
Membership No
Dependent Code
Practice Number
Procedure Codes plus cost (Inclusive of VAT)
Complete breakdown of laboratory Codes including cost and quantity
Date of Admission if hospitalisation is required
Hospital Name and Practice Number
Radiographs are necessary for all surgical in-hospital procedures (please email this)
Cephalometric tracing must be submitted for Orthodontic cases
Provider email or fax details
FOR ALL NUFWASA, FURNMED,CARECROSS,TRANSMED, MOTO HEALTH AND DISCOVERY
MEMBERS IT IS PART OF THE NETWORK PROVIDERS’ RESPONSIBILITY TO INFORM THESE
MEMBERS PRIOR TO PERFORMING PROCEDURES OUTSIDE OF THEIR BENEFITS OF THE
COSTS THAT THEY MAY BE RESPONSIBLE FOR.
ND
THE CONSENT BY MAIN MEMBER FOR PAYMENT FORM (ATTACHED ON 2 LAST PAGE) CAN BE
USED TO FACILITATE THIS INFORMATON SESSION WITH THE MEMBER.
DRC ONLY AUTHORISE OR PAY THE PROCEDURE CODES THAT THE PROVIDER PERFORMS. IF THE
MEMBER NEEDS TO BE HOSPITALISED THIS COMES FROM THE HOSPITAL BENEFIT OF THE
SCHEME, AND AS SUCH NEEDS TO BE AUTHORISED DIRECTLY WITH THE RELEVANT MEDICAL
SCHEME
GENERAL RULES AND PROTOCOLS
RULES:
Where a discrepancy exists between the tooth numbers and or treatment codes authorised, and those
that are reported on a dental claim, such codes will not be paid.
The reporting of two separate restorations of the same material, covering the same tooth surface twice
on the same day, will not attract benefit. Such restoration should be reported as a single treatment code.
If a procedure does not attract benefit; all other treatment associated with the specific event does not
receive benefit.
On extraction and filling codes tooth numbers cannot cross posterior quadrants but should be in a
st th nd rd
combination of 1 and 4 quadrants or 2 and 3 quadrants per visit.
4PROTOCOLS:
No Benefit for root canal treatment on third molars (wisdom teeth – 18/28/38/48) and primary teeth.
No Benefit for Crowns on third molars (wisdom teeth – 18/28/38/48).
No Benefit for Pontics on second molars (17/27/37/47).
No Benefit for Laboratory fabricated crowns on primary teeth.
High impact acrylic is not covered unless adequately motivated.
RESTORATIONS CANNOT BE CLAIMED ON THE SAME TOOTH NUMBER AND SERVICE DATE AS
TARIFF 8132, ONLY ADEQUATELY MOTIVATED CASES WILL BE CONSIDERED.
WHERE CLINICAL PROTOCOL RULES APPLY AND THE CLAIM / TARIFF CODE REJECT, A WRITTEN
MOTIVATION IS REQUIRED TO BE SUBMITTED TO motivation@dentalrisk.com TO BE CONSIDERED
FOR RE-PROCESSING.
GENERAL EXCLUSIONS
We list standard exclusions that are applied to all our clients but for ease of reference please contact our call
centre at 086 111 5057 to confirm if specific treatment is covered on a benefit option and should a dispute
arise only the rules of the scheme will be taken into consideration.
Benefits for restorations/crowns/bridges will not be applied towards the following:
Repairing of teeth damaged due to bruxism or toothbrush abrasion; erosion or fluorosis with no
secondary caries
to restore teeth for cosmetic reasons
where the member’s mouth is periodontally compromised
where the tooth has been recently restored to function
Benefits for amalgam restorations to be replaced with composite are only available where such treatment
is necessary to restore secondary caries. Replacement of non-carious amalgam fillings with resin fillings
is not covered.
Nutritional (8149) and tobacco counselling (8150)
Caries susceptibility (8122) and microbiological tests (8123)
Electrognathographic recordings (8508) and other such electronic analyses (8509)
Polishing of restorations
Ozone therapy
Metal base to full dentures, including laboratory cost
Resin bonding for restorations charged as a separate procedure
Dental bleaching (8310, 8308, 8309, 8311, 8325, 8327)
Conservative dental treatment (fillings; extractions and root canal therapy) for adults in-hospital
Professional oral hygiene procedures in-hospital
Laboratory costs, where the associated dental treatment is not covered and Laboratory delivery fees
Cost of gold, precious metal, semi-precious metal and platinum foil
Oral hygiene instruction (8151).
5IMPORTANT CONTACT DETAILS
For general information see our website www.dentalrisk.com
Dental Risk Company (Pty) Ltd OR PO Box 7824 OR (Tel) 086 111 5057
1040 Clifton Avenue Centurion (Fax) 086 687 1285
Clifton Court, 0046
Lyttelton Manor, Centurion
SPECIALISED DENTISTRY
Please note that DRC does not manage specific limits for specialised dentistry and you will need to contact
the relevant scheme to determine availability for the below options.
All specialised or in-hospital benefits for Liberty are assessed via pre-authorisation emailed to
auth@dentalrisk.com.
All in-hospital or orthodontic benefits for Profmed are assessed via pre-authorisation emailed to
dental@profmed.com.
PRE-AUTHORISATION SUMMARY
For benefit confirmation on specialised benefits, please contact the relevant medical schemes !
6BENEFITS
CARECROSS
CareCross and Affiliated Schemes
MEDICAL AID SCHEME OPTION
BANKMED Basic
DOMESTICARE Basic
ESSENTAIL MED Individuals: CareCross Option
Groups: CareCross Option
HORIZON Major Medical Plan CareCross
LIBERTY Bona Plus
MOTOHEALTH Custom
Essential
OCSACARE Silver
Gold
Gold Ackermans
Gold Scorpions
Gold No Waiting period
Gold 3 month waiting period
Gold Adcorp 3 month waiting period
Gold Massmart
Gold Truworths
OLD MUTUAL STAFF Network Plan
PLATINUM HEALTH PLATCAP option
REMEDI Standard Option
TOPMED Network Option
WOOLTRU Core Option
7CARECROSS: BASIC OPTION
Authorisations must be sent to CARECROSS HEALTH via fax to (021) 673-1811 or email to
dentalmotivations@carecross.co.za
Code Description Tariff Limitations
Consultations (includes cost of code 8110)
8101 Full mouth examination, charting and treatment planning 160.50 Every 6 months per member
8104 Examination or consultation for a specific problem, not requiring 77.80 Not within 4 weeks of 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs, per film 64.90 Maximum of 2 films per visit per
8112 Intra Oral radiographs, per film 64.90 member
8109 Infection control 14.40 Maximum of 2 per visit
8145 Local anaesthetic per visit 62.50 Maximum of 1 per visit
Preventative Codes
8155 Polish (all ages) 98.60 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 193.80 months per member
8161 Fluoride treatment (children) 98.60 Once every 6 months per
member younger than 12 years
8162 Fluoride treatment (adult) 98.60 Once every 6 months per
member older than 12 years
Extraction Codes
8201 Extraction single tooth 98.60 1 per quadrant per member per
visit
8202 Extraction each additional tooth in the same quadrant 39.70 4 and more require pre-
authorisation
Emergency Codes
8132 Emergency root canal treatment 161.20 Not covered on primary teeth
Restoration Codes: Posterior Amalgam and Resin fillings remunerated at the same tariff below
8341 Amalgam or Resin – one surface 196.10
(8367)
8342 Amalgam or Resin – two surfaces 241.80
Pre-authorisation required for
(8368)
more than 3 restorations per
8343 Amalgam or Resin – three surfaces 294.70
visit
(8369)
8344 Amalgam or resin – four or more surfaces 328.40
(8370)
8351 Resin - one surface 215.20
Pre-authorisation required for
8352 Resin - two surfaces 270.70
more than 2 restorations per
8353 Resin - three surfaces 323.50
visit
8354 Resin - four surfaces 360.90
8CARECROSS: BASIC PLUS DENTURES
Authorisations must be sent to CARECROSS HEALTH via fax to (021) 673-1811 or email to
dentalmotivations@carecross.co.za
Only applicable for:
BANKMED BASIC, MOTO HEALTH CUSTOM claims paid to full value of Scheme tariff
TOPMED NETWORK PLAN 20% CO-PAYMENT APPLIES
Code Description Tariff Limitations
8099 Lab Codes(detail codes required)
8233 Partial Denture - One tooth 455.80 Once every 24 months per
dependant
8234 Partial Denture - Two teeth 455.80 Once every 24 months per
dependant
8235 Partial Denture - Three teeth 682.10 Once every 24 months per
dependant
8236 Partial Denture - Four teeth 682.10 Once every 24 months per
dependant
8237 Partial Denture - Five teeth 682.10 Once every 24 months per
dependant
8238 Partial Denture - Six teeth 904.60 Once every 24 months per
dependant
8239 Partial Denture - Seven teeth 904.60 Once every 24 months per
dependant
8240 Partial Denture - Eight teeth 904.60 Once every 24 months per
dependant
8241 Partial Denture - Nine teeth and more 904.60 Once every 24 months per
dependant
8232 Full upper or lower denture 904.60 Once every 24 months per
dependant
8231 Full upper and lower denture 1590.40 Once every 24 months per
dependant
8269 Repair Denture 125.10 Twice per calendar year per
member
8259 Rebase of denture (laboratory) 371.70 Rebase complete or partial
denture (once a calendar year
per member)
8261 Remodel of denture 596.80 Rebase complete or partial
denture (once a calendar year
per member)
8263 Reline of denture (self curing acrylic) 235.60 Reline complete or partial
denture (once a calendar year
per member)
8275 Dental Lab Service 72.20 Twice per calendar year per
member
9DISCOVERY HEALTH
DISCOVERY KEYCARE PLUS AND KEYCARE ACCESS OPTION
QUANTUM KEYCARE OPTION
LA HEALTH KEYCARE OPTION
Code Description Tariff Limitations
54 PRACTICES
Consultations
8101 Full mouth examination, charting and treatment 159.40 2x per year, per member,180 day time lapse
planning applied
8104 Examination or consultation for a specific problem, 77.30 Not within 4 weeks of 8101, 8102, 8104
not requiring charting and treatment planning
Diagnostic Codes
8107 Intra-Oral radiographs per film 64.60 Maximum 7 per 365 days for codes 8107 and
8112 Intra-Oral radiographs per film 64.60 8112
8109 Infection Control 14.30 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 37.00 Will only be paid if code 8731, 9013, or 9011
instrumentation is claimed
8145 Local anaesthetic per visit 62.10 Once per visit
Preventative Codes
8155 Polish (all ages) 98.00 8155 and 8159, once per 6 months per
8159 Scale and Polish (older than 12 years) 192.40 member
8161 Fluoride treatment 98.00 Maximum 2 per year (once in 6 months)
younger than 12 years
Extraction Codes
8201 Extraction single tooth 98.00 Maximum 1 per quadrant per visit
8202 Extraction each additional tooth in the same 39.40 Maximum 7 per quadrant for adult patient and
quadrant 4 per quadrant for child
Emergency Codes
8132 Emergency root canal treatment 160.10 8132 cannot be claimed with 8131 or any
restoration, root canal and extraction codes.
Maximum of 1 per treatment date. Not
covered on primary teeth.
The subsequent filling will not be covered
after 8132 was performed if the root canal
treatment is skipped, email/scanned x-ray of
the filled canal will suffice.
Restoration Codes
8341 Amalgam – one surface 194.90
8342 Amalgam – two surfaces 240.20 Pre-authorisation required for more than 3
8343 Amalgam – three surfaces 292.80 restorations per visit.
8344 Amalgam – four or more surfaces 326.20 Three and four surface fillings on wisdom
8351 Resin - one surface 213.80 teeth require x-rays and prior pre-
8352 Resin - two surfaces 269.00 authorisation and approval.
8353 Resin - three surfaces 321.50 1 restoration code per tooth number in a 9
8354 Resin - four surfaces 358.60 month time period.
8367 Resin - one surface 231.90 Repairing of teeth damaged due to
8368 Resin - two surfaces 286.90 bruxism, toothbrush abrasion, erosion of
8369 Resin - three surfaces 346.60 fluorisis will not be covered
8370 Resin - four surfaces 372.80
Surgical Incisions
8731 Incision and drainage of abscess - intra - oral 156.20
9011 Incision and drainage of abscess - intra - oral 242.30
(pyogenic)
9013 Incision and drainage of abscess - intra - oral 331.30
(pyogenic)
10DISCOVERY HEALTH
DISCOVERY KEYCARE PLUS AND KEYCARE ACCESS OPTION
QUANTUM KEYCARE PLUS
LA HEALTH KEYCARE OPTION
Code Description Tariff Limitations
95 PRACTICES
Consultations
8101 Full mouth examination, charting and treatment planning 82.90 2 x per year, per member,180
day time lapse applied
8104 Examination or consultation for a specific problem, not requiring 64.70 Not within 4 weeks of 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs per film 62.10 Maximum 7 per 365 days for
8112 Intra Oral radiographs per film 62.10 codes 8107 and 8112
8109 Infection control 14.30 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 37.00 Will only be paid if code 9011 is
instrumentation claimed
8145 Local anaesthetic per visit 14.10 Once per visit
Preventative Codes
8155 Polish (all ages) 79.70 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 145.10 months per member
8161 Fluoride treatment 79.70 Maximum 2 per year (once in 6
months) younger than 12 years
Extraction Codes
8201 Extraction single tooth 92.80 Maximum 1 per quadrant per visit
8202 Extraction each additional tooth in the same quadrant 35.90 Maximum 7 per quadrant for
adult patient and 4 per quadrant
for child
Restoration Codes
8341 Amalgam – one surface 170.10 Pre-authorisation required for
8342 Amalgam – two surfaces 209.60 more than 3 restorations per
8343 Amalgam – three surfaces 255.50 visit.
8344 Amalgam – four or more surfaces 284.50 Three and four surface fillings
8351 Resin - one surface 205.60 on wisdom teeth require x-
8352 Resin - two surfaces 258.60 rays and prior pre-
8353 Resin - three surfaces 309.00 authorisation and approval.
8354 Resin - four surfaces 344.80 1 restoration code per tooth
8367 Resin - one surfaces 223.00 number in a 9 month time
8368 Resin - two surfaces 275.90 period.
8369 Resin - three surfaces 333.30 Repairing of teeth damaged
8370 Resin - four surfaces 358.50 due to bruxism, toothbrush
abrasion, erosion of fluorisis
will not be covered.
Surgical Incision
9011 Incision and drainage of abscess - intra - oral (pyogenic) 114.50
11FEDHEALTH – BLUE DOOR
Code Code Description Limitations Fedhealth Tariff
Blue Door
2013 Benefits, tariffs and limitations will be forwarded as soon as we receive it from the Scheme/Administrator
12LIBERTY TITAN AND TITAN SELECT OPTIONS
Crowns and bridges 1 crown per family per year Authorisation from DRC
Metal frame dentures One frame in 5 years per member Authorisation from DRC
Orthodontics Comprehensive 65% of Scheme rate Member to pay balance Authorisation
from DRC
Implants and Associated No benefit No benefit
Surgery
Surgery Covered at the Scheme rate - Authorisation from DRC
Admission protocols apply
PLEASE NOTE LATE PRE-AUTHORISATION FOR LIBERTY WILL NOT BE COVERED
LIBERTY – TITAN AND TITAN SELECT
Code Description Tariff Limitations
Consultations
8101 Full mouth examination, charting and treatment planning 164.30 Once per member per benefit
year (180 days apart from
previous 8101)
8104 Examination or consultation for a specific problem, not requiring 79.70 Not within 4 weeks of an 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs per film 66.60 Code 8107 and 8112 cannot be
charged more than 7 times (per
year)
8112 Intra Oral radiographs per film 66.60 Code 8112 and 8107 cannot be
charged more than 7 times (per
year)
8115 Extra-oral radiograph – panoramic 265.90 Maximum 2 Panoramic
radiograph per member per
treatment plan – per 24 months
(six month time lapse applies)
8113 Intra-oral radiograph – occlusal 114.60 Only applicable on Orthodontics
8114 Extra-oral radiograph - hand-wrist 265.90 Only applicable on Orthodontics
8116 Extra-oral radiograph – cephalometric 265.90 Only applicable on Orthodontics
8121 Oral and/or facial image (digital/conventional) 71.60 Only applicable on Orthodontics
8109 Infection control 14.80 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 38.10 Maximum 1 per visit
instrumentation
8145 Local anaesthetic per visit 64.10 Once per visit
Preventative Codes
8155 Polish (all ages) 101.00 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 198.30 months per member
8161 Fluoride treatment (children) 101.00 Once per 6 months per member
must be younger than 12 years
8162 Fluoride treatment (adult) 101.00 Once per 6 months per member
must be older than 12 years
8167 Treatment of hypersensitive dentine per visit 77.20 Once per 6 months per member
(not with 8159 on the same day)
Extraction Codes
8201 Extraction first tooth 101.00 Maximum 1 per quadrant, the
second and additional
extractions must be claimed
13LIBERTY – TITAN AND TITAN SELECT
Code Description Tariff Limitations
under code 8202
8202 Extraction each additional tooth in the same quadrant 40.70 Maximum 7 per quadrant for
adult member and 4 per
quadrant for children
Emergency Codes
8132 Emergency root canal treatment 165.00 Not covered on primary teeth
8131 Emergency dental treatment where no other treatment item is 101.00
applicable
Restoration Codes
8163 Dental sealant 66.60 Maximum of 8 can be charged
per member, 2 per quadrant on
members younger than 16 years
(excluded from benefits if
member is older than 16)
8341 Amalgam – one surface 200.90
8342 Amalgam – two surfaces 247.60
8343 Amalgam – three surfaces 301.70 Pre-authorisation required
8344 Amalgam – four or more surfaces 336.30 for more than 5 restorations
per visit
8351 Resin - one surface 220.30
1 restoration code per tooth
8352 Resin - two surfaces 277.20
number in a 9 month time
8353 Resin - three surfaces 331.30
period
8354 Resin - four surfaces 369.60
Multiple fillings on anterior
8367 Resin - one surface 239.00
teeth only per treatment plan
8368 Resin - two surfaces 295.60 and motivation received
8369 Resin - three surfaces 357.30
8370 Resin - four surfaces 384.30
Root Canal
8307 Pulp amputation (pulpotomy) 131.70 Primary teeth only
8332 Root canal preparatory visit - single canal tooth 101.00
8333 Root canal preparatory visit - multi canal tooth 141.50
8335 Root canal obturation - anterior and premolars - first canal 458.30
8328 Root canal obturation - anterior and premolars - each additional 187.30
canal
8336 Root canal obturation - posteriors - first canal 630.60
8337 Root canal obturation - posteriors - each additional canal 187.30
8338 Root canal therapy - anterior and premolars - first canal 701.00
Only covered on permanent
8329 Root canal therapy - anterior and premolars - each additional 234.10
teeth
canal
8339 Root canal therapy - posteriors - first canal 963.10
8340 Root canal therapy - posteriors - each additional canal 234.10
8334 Re-preparation of previously obturated root canal 149.10
8635 Apexification/recalcification – per visit 134.30
8330 Removal of root canal obstruction 131.70
8136 Access through a prosthetic crown or inlay to facilitate root 90.00
canal treatment
Dentures
8233 Partial Denture - One tooth 466.70
8234 Partial Denture - Two teeth 466.70
8235 Partial Denture - Three teeth 698.40
8236 Partial Denture - Four teeth 698.40
8237 Partial Denture - Five teeth 698.40 One per jaw every 4 years
8238 Partial Denture - Six teeth 926.30 for patients older than 21
8239 Partial Denture - Seven teeth 926.30 years
8240 Partial Denture - Eight teeth 926.30
8241 Partial Denture - Nine teeth and more 926.30
8232 Full upper or lower denture 1003.90
8231 Full upper and lower denture 1628.30
8269 Repair Denture 128.00
8259 Rebase of denture (laboratory) 380.60
8261 Remodel of denture 611.00
14LIBERTY – TITAN AND TITAN SELECT
Code Description Tariff Limitations
8263 Reline of denture (self curing acrylic) 241.40
8267 Soft base reline per denture 555.50
Hospitalisation and Anaesthetics
8141 Laughing gas in dental room 73.90 Full Benefit
8143 38.10
8144 IV Conscious sedation in room 44.40 Clinical protocols apply - must
be authorised
8140 General anaesthetic in hospital 163.90 Admission protocols apply -
8499 0.00 must be authorised
Hospital benefit for children 7
years and younger is limited
to 1 admission per lifetime
Specialised Dentistry - All specialised dentistry requires authorisation
Crown and Bridges 1 crown per family per year –
older than 16 years
8281 Metal Frame Dentures 1089.00 1 frame in 5 years per patient –
older than 21 years
Orthodontics Comprehensive 65% of Liberty
Medical Scheme Dental Tariff -
member must be younger than
21 years
Implants No Benefits
Surgery Covered at the Liberty Medical
Scheme Dental Tariff Admission
protocols apply. Surgical
impactions in-hospital require
authorisation. Please supply
panoramic radiograph with
application.
8275 Dental Lab Service 73.90
8099 Lab Codes (detailed codes required)
15LIBERTY PROTOCOLS
Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth.
In the event that the re-root canal treatment fails, benefits will be available for an apisectomy (subject to
pre-authorisation and, rules and protocols).
Late pre-authorisation and pre-authorisations 48 hours before a planned admission will not attract
benefit; no pre-auth no payments.
Pre-authorisation for Emergency – within 48 hours of admission.
Hospital benefit for children 7 years and younger is limited to 1 admission per lifetime.
LIBERTY EXCLUSIONS
Electrognathographic recordings and other such electronic analyses
Metal base to full dentures, including the laboratory cost
Soft base to new dentures
Diagnostic dentures
Provisional crowns
Laboratory cost of provisional crowns and emergency crowns
Ozone therapy
Resin bonding for restorations charged as separate procedure
Dental bleaching and porcelain veneers
Laboratory fabricated crowns on primary teeth
Gingivectomy
Periodontal flap surgery and tissue grafting
Orthodontic re-treatment, Lingual orthodontics
Orthognathic (jaw correction) surgery and related hospital cost
Sinus Lift
Surgery associated with dental implants; in hospital dentectomies; hospitalisations for surgical tooth exposure
for orthodontic reasons.
Bone augmentations
Bone and other tissue regeneration procedures
Laboratory delivery fees
Laboratory cost associated with mouth guards (including material).
Cost of Mineral Trioxide
Oral hygiene instructions; perio chip; snoring appliances; four surface fillings of third molar;
Cost of gold, precious metal, semi-precious metal and platinum foil
Cost of invisible retainer material
Cost of bone regeneration material, Cost of implant components (including laboratory costs)
Surgery associated with dental implants
Dental implants
16MOTO HEALTH – CLASSIC OPTION
Code Description Tariff Limitations
Consultations: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum
at (0861000300)
8101 Full mouth examination, charting and treatment planning 163.90 2 per member per benefit year,
180 days apart from previous
8101)
8104 Examination or consultation for a specific problem, not requiring 79.40 Not within 4 weeks of an 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with
Momentum at (0861000300)
8107 Intra Oral radiographs per film 66.40 More than 7 times per year
requires pre-authorisation
8112 Intra Oral radiographs per film 66.40 More than 7 times per year
requires pre-authorisation
8115 Extra-oral radiograph – panoramic 264.80 1 Panoramic radiograph per
member per treatment plan –
per 24 months
8113 Intra-oral radiograph – occlusal 114.20 Only applicable on Orthodontics
8114 Extra-oral radiograph - hand-wrist 264.80 Only applicable on Orthodontics
8116 Extra-oral radiograph – cephalometric 264.80 Only applicable on Orthodontics
8121 Oral and/or facial image (digital/conventional) 71.20 Only applicable on Orthodontics
8109 Infection control 14.80 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 38.20 Maximum 1 per visit
instrumentation
8145 Local anaesthetic per visit 63.90 Once per visit
Preventative Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with
Momentum at (0861000300)
8155 Polish (all ages) 100.70 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 197.50 months per member
8161 Fluoride treatment (children) 100.70 Once per 6 months per member
must be younger than 12 years
8162 Fluoride treatment (adult) 100.70 Once per 6 months per member
must be older than 12 years
8167 Treatment of hypersensitive dentine per visit 77.40 Once per 6 months per member
(not with 8159 on the same day)
Extraction Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with
Momentum at (0861000300)
8201 Extraction first tooth 100.70 Maximum 1 per quadrant, the
second and additional
extractions must be claimed
under code 8202
8202 Extraction each additional tooth in the same quadrant 40.50 Maximum 7 per quadrant for
adult member and 4 per
quadrant for children
Emergency Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with
Momentum at (0861000300)
8132 Emergency root canal treatment 164.40 Not covered on primary teeth
8131 Emergency dental treatment where no other treatment item is 100.70
applicable
17MOTO HEALTH – CLASSIC OPTION
Code Description Tariff Limitations
Restoration Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with
Momentum at (0861000300)
8163 Dental sealant 66.40 Maximum of 8 can be charged
per member, 2 per quadrant on
members younger than 16 years
(excluded from benefits if
member is older than 16)
8341 Amalgam – one surface 200.00
8342 Amalgam – two surfaces 246.60
8343 Amalgam – three surfaces 300.50 Pre-authorisation required
8344 Amalgam – four or more surfaces 334.70 for more than 3 restorations
per visit
8351 Resin - one surface 219.50
1 restoration code per tooth
8352 Resin - two surfaces 276.00
number in a 9 month time
8353 Resin - three surfaces 329.90
period
8354 Resin - four surfaces 368.10
Multiple fillings on anterior
8367 Resin - one surface 238.00
teeth only per treatment plan
8368 Resin - two surfaces 294.40 and motivation received
8369 Resin - three surfaces 355.70
8370 Resin - four surfaces 382.40
Root Canal: Specialised Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at
(0861000300)
8307 Pulp amputation (pulpotomy) 131.40 Primary teeth only
8332 Root canal preparatory visit - single canal tooth 100.70
8333 Root canal preparatory visit - multi canal tooth 141.00
8335 Root canal obturation - anterior and premolars - first canal 456.10
8328 Root canal obturation - anterior and premolars - each additional 186.70
canal
8336 Root canal obturation - posteriors - first canal 627.70
8337 Root canal obturation - posteriors - each additional canal 186.70
8338 Root canal therapy - anterior and premolars - first canal 697.70
Only covered on permanent
8329 Root canal therapy - anterior and premolars - each additional 233.10
teeth
canal
8339 Root canal therapy - posteriors - first canal 958.70
8340 Root canal therapy - posteriors - each additional canal 233.10
8334 Re-preparation of previously obturated root canal 148.50
8635 Apexification/recalcification – per visit 133.80
8330 Removal of root canal obstruction 131.40
8136 Access through a prosthetic crown or inlay to facilitate root canal 89.70
treatment
Dentures: Specialised Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at
(0861000300). DRC pre-authorisation required.
8233 Partial Denture - One tooth 464.70
8234 Partial Denture - Two teeth 464.70
8235 Partial Denture - Three teeth 695.40
8236 Partial Denture - Four teeth 695.40
8237 Partial Denture - Five teeth 695.40
One per jaw every 4 years
8238 Partial Denture - Six teeth 922.20
for patients older than 21
8239 Partial Denture - Seven teeth 922.20
years
8240 Partial Denture - Eight teeth 922.20
8241 Partial Denture - Nine teeth and more 922.20
8232 Full upper or lower denture 999.30
8231 Full upper and lower denture 1620.7
0
8269 Repair Denture 127.50
8259 Rebase of denture (laboratory) 379.00
8261 Remodel of denture 608.30
8263 Reline of denture (self curing acrylic) 240.40
8267 Soft base reline per denture 553.20
18MOTO HEALTH – CLASSIC OPTION
Code Description Tariff Limitations
Surgical Dentistry: Subject to Pre-Authorisation and Managed Care Protocols. Payable at 100% of MHC Rate
subject to Annual Savings Limit. Please confirm benefits with Momentum at (0861000300)
8141 Laughing gas in dental room 73.70 Full Benefit
8143 38.20
8144 IV Conscious sedation in room 44.30 Clinical protocols apply - must
be authorised
8140 General anaesthetic in hospital 163.10 Admission protocols apply -
8499 0.00 must be authorised
Hospital benefit for children 7
years and younger is limited
to 1 admission per lifetime
Specialised Dentistry: All specialised dentistry requires authorisation payable 100% of MHC Rate at a preferred
Provider subject to Annual Savings Limit. Please confirm benefits with Momentum at
(0861000300)
Crown and Bridges 1 crown per family per year –
older than 16 years
8281 Metal Frame Dentures 1084.0 1 frame in 5 years per patient –
0 older than 21 years
8275 Dental Lab Service 73.70
8099 Lab Codes (detailed codes required)
MOTO HEALTH – CLASSIC OPTION
MOTO HEALTH PROTOCOLS
Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth. In the event
that the re-root canal treatment fails, benefits will be available for an apisectomy.
Crowns and four surface fillings on third molars.
Late pre-authorisation and pre-authorisations 48 hours before a planned admission will not attract benefit; no pre-
auth no payments.
Pre-authorisation for Emergency – within 48 hours of admission.
Hospitalisation for surgical tooth exposure for orthodontic reasons; dentectomies and apisectomies subject to
Transmed protocols.
EXCLUSIONS FOR MOTO HEALTH CLASSIC OPTION
Treatment mentioned in Rule where no authorisation was given by the Fund
The cost of gold, metal or other inlays in a denture or crown
Fee for after hours visits which the Fund considers as convenience visits
Bleaching of vital teeth
Unregistered items and items listed as “by agreement” or “not applicable” in the tariff code listing
Lingual orthodontic treatment
Services which deviate from the available guidelines of the Department of Health and which are deemed to be excluded
from benefits after evaluation of the available information
Gum guards for sport purposes
Laboratory costs, which according to the Fund’s norms and judgement, seem to be above the general cost claimed by
other dental services providers and dental laboratories treating similar conditions
Services or procedures which are regarded by the Fund as cosmetic, when alternative functional services exist (in which
case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative
service)
19MOTO HEALTH – OPTIMUM OPTION
Code Description Tariff Limitations
Consultations Codes: Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of:
Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at
(0861000300)
8101 Full mouth examination, charting and treatment planning 163.90 2 per member per benefit year
,180 days apart from previous
8101
8104 Examination or consultation for a specific problem, not requiring 79.40 Not within 4 weeks of an 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs per film 66.40 more than 7 times per year
requires pre-authorisation
8112 Intra Oral radiographs per film 66.40 more than 7 times per year
requires pre-authorisation
8115 Extra-oral radiograph – panoramic 264.80 Maximum 2 Panoramic
radiograph per member per
treatment plan – per 24 months
(six month time lapse applies)
8113 Intra-oral radiograph – occlusal 114.20 Only applicable on Orthodontics
8114 Extra-oral radiograph - hand-wrist 264.80 Only applicable on Orthodontics
8116 Extra-oral radiograph – cephalometric 264.80 Only applicable on Orthodontics
8121 Oral and/or facial image (digital/conventional) 71.20 Only applicable on Orthodontics
8109 Infection control 14.80 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 38.20 Maximum 1 per visit
instrumentation
8145 Local anaesthetic per visit 63.90 Once per visit
Preventative Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of:
Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at
(0861000300)
8155 Polish (all ages) 100.70 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 197.50 months per member
8161 Fluoride treatment (children) 100.70 Once per 6 months per member
must be younger than 12 years
8162 Fluoride treatment (adult) 100.70 Once per 6 months per member
must be older than 12 years
8167 Treatment of hypersensitive dentine per visit 77.40 Once per 6 months per member
(not with 8159 on the same day)
Extraction Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of:
Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at
(0861000300)
8201 Extraction first tooth 100.70 Maximum 1 per quadrant, the
second and additional
extractions must be claimed
under code 8202
8202 Extraction each additional tooth in the same quadrant 40.50 Maximum 7 per quadrant for
adult member and 4 per
quadrant for children
Emergency Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of:
Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at
(0861000300)
8132 Emergency root canal treatment 164.40 Not covered on primary teeth
8131 Emergency dental treatment where no other treatment item is 100.70
applicable
20MOTO HEALTH – OPTIMUM OPTION
Code Description Tariff Limitations
Restoration Codes: Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of Member =
R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)
8163 Dental sealant 66.40 Maximum of 8 can be charged
per member, 2 per quadrant on
members younger than 16 years
(excluded from benefits if
member is older than 16)
8341 Amalgam – one surface 200.00
8342 Amalgam – two surfaces 246.60
8343 Amalgam – three surfaces 300.50 Pre-authorisation required
8344 Amalgam – four or more surfaces 334.70 for more than 3 restorations
per visit
8351 Resin - one surface 219.50
1 restoration code per tooth
8352 Resin - two surfaces 276.00
number in a 9 month time
8353 Resin - three surfaces 329.90
period
8354 Resin - four surfaces 368.10
Multiple fillings on anterior
8367 Resin - one surface 238.00
teeth only per treatment plan
8368 Resin - two surfaces 294.40 and motivation received
8369 Resin - three surfaces 355.70
8370 Resin - four surfaces 382.40
Root Canal Codes: Specialised Dentistry subject to an Annual Sub Limit and the Annual Day to Day limit of:
Member = R9268.00 and Member + = R13780.00. Please confirm benefits with Momentum at
(0861000300)
8307 Pulp amputation (pulpotomy) 131.40 Primary teeth only
8332 Root canal preparatory visit - single canal tooth 100.70
8333 Root canal preparatory visit - multi canal tooth 141.00
8335 Root canal obturation - anterior and premolars - first canal 456.10
8328 Root canal obturation - anterior and premolars - each additional 186.70
canal
8336 Root canal obturation - posteriors - first canal 627.70
8337 Root canal obturation - posteriors - each additional canal 186.70
8338 Root canal therapy - anterior and premolars - first canal 697.70
Only covered on permanent
8329 Root canal therapy - anterior and premolars - each additional 233.10
teeth
canal
8339 Root canal therapy - posteriors - first canal 958.70
8340 Root canal therapy - posteriors - each additional canal 233.10
8334 Re-preparation of previously obturated root canal 148.50
8635 Apexification/recalcification – per visit 133.80
8330 Removal of root canal obstruction 131.40
8136 Access through a prosthetic crown or inlay to facilitate root canal 89.70
treatment
Dentures Codes: Specialised Dentistry subject to an Annual Sub Limit and the Annual Day to Day limit of:
Member = R9268.00 and Member + = R13780.00. Please confirm benefits with Momentum at
(0861000300)
8233 Partial Denture - One tooth 464.70
8234 Partial Denture - Two teeth 464.70
8235 Partial Denture - Three teeth 695.40
8236 Partial Denture - Four teeth 695.40
8237 Partial Denture - Five teeth 695.40 One per jaw every 4 years
8238 Partial Denture - Six teeth 922.20 for patients older than 21
8239 Partial Denture - Seven teeth 922.20 years
8240 Partial Denture - Eight teeth 922.20
8241 Partial Denture - Nine teeth and more 922.20
8232 Full upper or lower denture 999.30
8231 Full upper and lower denture 1620.70
8269 Repair Denture 127.50
8259 Rebase of denture (laboratory) 379.00
8261 Remodel of denture 608.30
8263 Reline of denture (self curing acrylic) 240.40
8267 Soft base reline per denture 553.20
21MOTO HEALTH – OPTIMUM OPTION
Code Description Tariff Limitations
Surgical Dentistry: Subject to Pre-Authorisation and Managed Care Protocols. Payable at 100% of MHC Rate
subject to an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268..00 and
Member + = R13780.00. Please confirm benefits with Momentum at (0861000300)
8141 Laughing gas in dental room 73.70 Full Benefit
8143 38.20
8144 IV Conscious sedation in room 44.30 Clinical protocols apply - must
be authorised
8140 General anaesthetic in hospital 163.10 Admission protocols apply -
8499 0.00 must be authorised
Hospital benefit for children 7
years and younger is limited
to 1 admission per lifetime
Specialised Dentistry: All specialised dentistry requires authorisation. Payable at 100% of MHC Rate subject to
an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268.00 and Member
+ = R13780.00. Please confirm benefits with Momentum at (0861000300)
Crown and Bridges 1 crown per family per year –
older than 16 years
8281 Metal Frame Dentures 1084.00 1 frame in 5 years per patient –
older than 21 years
Orthodontics member must be younger than
21 years
Implants No Benefits
8275 Dental Lab Service 73.70
8099 Lab Codes (detailed codes required)
MOTO HEALTH – OPTIMUM OPTION
MOTO HEALTH PROTOCOLS
Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth. In the event
that the re-root canal treatment fails, benefits will be available for an apisectomy.
Crowns and four surface fillings on third molars.
Late pre-authorisation and pre-authorisations 48 hours before a planned admission will not attract benefit; no pre-
auth no payments.
Pre-authorisation for Emergency – within 48 hours of admission.
Hospitalisation for surgical tooth exposure for orthodontic reasons; dentectomies and apisectomies subject to
Transmed protocols.
EXCLUSIONS FOR MOTO HEALTH OPTIMUM OPTION
Treatment mentioned in Rule where no authorisation was given by the Fund
The cost of gold, metal or other inlays in a denture or crown
Fee for after hours visits which the Fund considers as convenience visits
Bleaching of vital teeth
Unregistered items and items listed as “by agreement” or “not applicable” in the tariff code listing
Lingual orthodontic treatment
Services which deviate from the available guidelines of the Department of Health and which are deemed to be excluded
from benefits after evaluation of the available information
Gum guards for sport purposes
Laboratory costs, which according to the Fund’s norms and judgement, seem to be above the general cost claimed by
other dental services providers and dental laboratories treating similar conditions
Services or procedures which are regarded by the Fund as cosmetic, when alternative functional services exist (in which
case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative
service)
22NUFAWSA: STANDARD AND SELECT OPTIONS
FURNMED
Code Description Tariff Limitations
54 PRACTICES
Consultations
8101 Full mouth examination, charting and treatment planning 162.10 Once every 6 months
8104 Examination or consultation for a specific problem, not requiring 78.60 Not within 4 weeks after 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs, per film 65.70
Only 2 per member per year
8112 Intra Oral radiographs, per film 65.70
8109 Infection control 14.60 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 37.60 Only 1 per visit
instrumentation
8145 Local anaesthetic per visit 63.20 Only 1 per visit
Preventative Codes
8155 Polish (all ages) Price? 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 195.60 months per member
8167 Treatment of hypersensitive dentine, per visit 76.50
Extraction Codes
8201 Extraction single tooth 99.60 Only 1 per quadrant per member
per visit
8202 Extraction each additional tooth in the same quadrant 40.10 4 and more require authorisation
Emergency Codes
8132 Emergency root canal treatment 162.80 Not covered on primary teeth
8131 Emergency dental treatment where no other treatment item is 99.60
applicable
Restoration Codes
8341 Amalgam – one surface 198.00 Pre-authorisation required for
8342 Amalgam – two surfaces 244.10 more than 3 restorations per
8343 Amalgam – three surfaces 297.60 year
8344 Amalgam – four or more surfaces 331.60 1 restoration code per tooth
number in a 9 month time
period
Specialised Dentistry – Pre-authorisation required for all specialised procedures and dentures. Items payable from
specialised rand limit is dentures and root canal treatment.
Specialised rand limit available:
Nufawsa Standard Option = R1500.00
Nufawsa Select Option = R600.00
Furnmed = R1000.00 per family per year, dentures allowed 1 per dependant per 2 years depending on limit
23NUFAWSA: STANDARD AND SELECT OPTIONS
FURNMED
Code Description Tariff Limitations
95 PRACTICES
Consultations
8101 Full mouth examination, charting and treatment planning 84.30 Once every 6 months
8104 Examination or consultation for a specific problem, not requiring 65.90 Not within 4 weeks after 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs, per film 63.20
Only 2 per member per year
8112 Intra Oral radiographs, per film 63.20
8109 Infection control 14.60 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 37.60 Only 1 per visit
instrumentation
8145 Local anaesthetic per visit 14.40 Only 1 per visit
Preventative Codes
8155 Polish (all ages) Price? 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 147.50 months per member
8167 Treatment of hypersensitive dentine, per visit 64.90
Extraction Codes
8201 Extraction single tooth 94.40 Only 1 per quadrant per member
per visit
8202 Extraction each additional tooth in the same quadrant 36.60 4 and more require authorisation
Emergency Codes
8131 Emergency dental treatment where no other treatment item is 84.30
applicable
Restoration Codes
8341 Amalgam – one surface 172.90 Pre-authorisation required for
8342 Amalgam – two surfaces 213.10 more than 3 restorations per
8343 Amalgam – three surfaces 259.70 year
8344 Amalgam – four or more surfaces 289.30 1 restoration code per tooth
number in a 9 month time
period
Specialised Dentistry – Pre-authorisation required for all specialised procedures and dentures. Items payable from
specialised rand limit is dentures and root canal treatment
Specialised rand limit available:
Nufawsa Standard Option = R1500.00
Nufawsa Select Option = R600.00
Furnmed = R1000.00 per family per year, dentures allowed 1 per dependant per 2 years depending on limit
24PROFMED
PROFMED: PROPINNACLE, PROSECURE PLUS AND PROSECURE
All in-hospital procedures DRC Protocols apply Authorisation from DRC
Orthodontics DRC Protocols apply Authorisation from DRC
PLEASE NOTE FOR PROFMED NO BENEFIT BOOKING IS DONE AND AS SUCH THE
AUTHORISATION CANNOT BE CONSIDERED A GUARANTEE OF PAYMENT
Option Limits Tariff Authorisation
Yes/No
Day-to-day benefit Subject to day-to-day limit Paid at Scheme Tariff No
Specialised benefit Subject to specialised limit Paid at Scheme Tariff Only for in-hospital
procedures
Orthodontic Subject to specialised limit Paid at Scheme Tariff Yes
In-hospital removal of Subject to specialised limit Paid at Scheme Tariff Yes
impactions
Crowns and Bridges Subject to specialised limit Paid at Scheme Tariff No
Dentures Subject to specialised and day Paid at Scheme Tariff No
to day limit
Code Description Tariff Limitations
Consultations
8101 Full mouth examination, charting and treatment planning 164.30 Twice a year – 6 month time
lapse applies
8104 Examination or consultation for a specific problem, not requiring 79.60 Not within 4 weeks of an 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
8107 Intra Oral radiographs per film 66.60 Code 8112 and 8107 cannot be
8112 Intra Oral radiographs per film 66.60 charged more than 7 times per
visit
8115 Extra-oral radiograph – panoramic 266.00 Maximum 2 Panoramic
radiograph per treatment plan -
time period 24 months (6 month
time lapse applies)
8113 Intra-oral radiograph – occlusal 114.60
8114 Extra-oral radiograph - hand-wrist 266.00
Only applicable on Orthodontics
8116 Extra-oral radiograph – cephalometric 266.00
8121 Oral and/or facial image (digital/conventional) 71.40
8109 Infection control 14.70 Maximum 3 per visit
8110 Provision of heat or vapour sterilised and wrapped 38.20
instrumentation Maximum 1 per visit
8145 Local anaesthetic per visit 64.10
Preventative Codes
8155 Polish (all ages) 100.90 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 198.30 months per member
8161 Fluoride treatment (children) 100.90 Once a year per member
younger than 12 years
8162 Fluoride treatment (adult) 100.90 Once a year per member older
than 12 years
8167 Treatment of hypersensitive dentine, per visit 77.60 Once every 6 months per
member younger than 12 years
(not with 8159 on the same day)
25PROFMED
PROFMED: PROPINNACLE, PROSECURE PLUS AND PROSECURE
All in-hospital procedures DRC Protocols apply Authorisation from DRC
Orthodontics DRC Protocols apply Authorisation from DRC
PLEASE NOTE FOR PROFMED NO BENEFIT BOOKING IS DONE AND AS SUCH THE
AUTHORISATION CANNOT BE CONSIDERED A GUARANTEE OF PAYMENT
Extraction Codes
8201 Extraction single tooth 100.90 Maximum 1 per quadrant the
second and additional extractions
must be claimed under code
8202
8202 Extraction each additional tooth in the same quadrant 40.60 Maximum 7 per quadrant for
adult member and 4 per quadrant
for child
Restoration Codes
8341 Amalgam – one surface 200.90
8342 Amalgam – two surfaces 247.60
8343 Amalgam – three surfaces 301.80
8344 Amalgam – four or more surfaces 336.20
8351 Resin - one surface 220.40
8352 Resin - two surfaces 277.20 1 restoration code per tooth
8353 Resin - three surfaces 331.30 number in a 9 month time period
8354 Resin - four surfaces 369.60
8367 Resin - one surface 238.90
8368 Resin - two surfaces 295.60
8369 Resin - three surfaces 357.20
8370 Resin - four surfaces 384.30
Emergency Codes
8132 Emergency root canal treatment 165.00 Not covered on primary teeth
8131 Emergency dental treatment where no other treatment item is 100.90
applicable
Root Canal
8307 Pulp amputation (pulpotomy) 131.80 Primary teeth only
8332 Root canal preparatory visit - single canal tooth 100.90
8333 Root canal preparatory visit - multi canal tooth 141.50
8335 Root canal obturation - anterior and premolars - first canal 458.20
8328 Root canal obturation - anterior and premolars - each additional 187.40
canal
8336 Root canal obturation - posteriors - first canal 630.70
8337 Root canal obturation - posteriors - each additional canal 187.40
8338 Root canal therapy - anterior and premolars - first canal 700.90
8329 Root canal therapy - anterior and premolars - each additional 234.10 Only covered on permanent teeth
canal
8339 Root canal therapy - posteriors - first canal 963.10
8340 Root canal therapy - posteriors - each additional canal 234.10
8334 Re-preparation of previously obturated root canal 149.00
8635 Apexification/recalcification – per visit 134.30
8330 Removal of root canal obstruction 131.80
8136 Access through a prosthetic crown or inlay to facilitate root canal 89.90
treatment
26PROFMED: HOSPITAL PLANS
PRO ACTIVE AND PRO ACTIVE PLUS
BENEFITS COVERED FOR PRO ACTIVE AND PRO ACTIVE PLUS
In-Hospital benefit only
Subject to pre-authorisation
Multiple admissions will not be covered unless comprehensively motivated.
In-hospital treatments which include the following 2 case scenarios only:
1. Wisdom impaction removals
Code Description Tariff
8941 Surgical removal of impacted tooth - first tooth 723.10
8943 Surgical removal of impacted tooth - second tooth 387.90
8945 Surgical removal of impacted tooth - third and subsequent teeth 220.40
2. Extensive basic dental treatment for children 8 years and younger.
27TRANSMED: PRIVATE NETWORK
Code Description Tariff Limitations
Consultations
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8101 Full mouth examination, charting and treatment planning 163.60 Once per member per benefit
year (180 days apart from
previous 8101)
8104 Examination or consultation for a specific problem, not requiring 79.30 Not within 4 weeks of an 8101,
charting and treatment planning 8102, 8104
Diagnostic Codes
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8107 Intra Oral radiographs per film 66.20 Code 8107 and 8112 cannot be
charged more than 7 times (per
year)
8112 Intra Oral radiographs per film 66.20 Code 8112 and 8107 cannot be
charged more than 7 times (per
year)
8115 Extra-oral radiograph – panoramic 264.80 Maximum 1 Panoramic
radiograph per member per
treatment plan – per 12 months
(365 DAYS time lapse applies)
8113 Intra-oral radiograph – occlusal 114.10 Only applicable on Orthodontics
8114 Extra-oral radiograph - hand-wrist 264.80 Only applicable on Orthodontics
8116 Extra-oral radiograph – cephalometric 264.80 Only applicable on Orthodontics
8121 Oral and/or facial image (digital / conventional) 71.20 Only applicable on Orthodontics
8109 Infection control 14.70 Maximum 2 per visit
8110 Provision of heat or vapour sterilised and wrapped 37.90 Maximum 1 per visit
instrumentation
8145 Local anaesthetic per visit 63.80 Once per visit
Preventative Codes
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8155 Polish (all ages) 100.40 8155 and 8159, once per 6
8159 Scale and Polish (older than 12 years) 197.50 months per member
8161 Fluoride treatment (children) 100.40 Once per 6 months per member
must be younger than 12 years
8162 Fluoride treatment (adult) 100.40 Once per 6 months per member
must be older than 12 years
8167 Treatment of hypersensitive dentine per visit 77.20 Once per 6 months per member
(not with 8159 on the same day)
Extraction Codes
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered (more than 3
of any code require pre-authorisation,note limit of 2 on 8937)
8201 Extraction first tooth 100.40 Maximum 1 per quadrant, the
second and additional extractions
must be claimed under code
8202
8202 Extraction each additional tooth in the same quadrant 40.40 More than 2 require pre-
authorisation. Maximum 7 per
quadrant per permanent dentition
and 4 per primary dentition
8937 Surgical removal of erupted tooth 434.20 More than 2 require pre-
authorisation
Emergency Codes
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8131 Emergency dental treatment where no other treatment item is 100.40
applicable
8132 Emergency root canal treatment 164.20 Not covered on primary teeth
28TRANSMED: PRIVATE NETWORK
Code Description Tariff Limitations
Restoration Codes - authorization required on quantity, see limitations.
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8163 Dental sealant 66.20 Maximum of 4 can be charged
per member, 1 per quadrant on
members younger than 16 years.
1st molars only (excluded from
benefits if member is older than
16)
8341 Amalgam – one surface 199.80
8342 Amalgam – two surfaces 246.40
8343 Amalgam – three surfaces 300.40 Pre-authorisation required for
8344 Amalgam – four or more surfaces 334.70 more than 3 restorations per
visit.
8351 Resin - one surface 219.40
1 restoration code per tooth
8352 Resin - two surfaces 275.90
number in a 9 month time
8353 Resin - three surfaces 329.70
period.
8354 Resin - four surfaces 367.70
Multiple fillings on anterior
8367 Resin - one surface 237.80
teeth only per treatment plan
8368 Resin - two surfaces 294.30 and motivation received
8369 Resin - three surfaces 355.60
8370 Resin - four surfaces 382.40
Root Canal
Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.
8307 Pulp amputation (pulpotomy) 131.20 Primary teeth only
8332 Root canal preparatory visit - single canal tooth 100.30
8333 Root canal preparatory visit - multi canal tooth 140.90
8335 Root canal obturation - anterior and premolars - first canal 456.00
8328 Root canal obturation - anterior and premolars - each additional 186.40
canal
8336 Root canal obturation - posteriors - first canal 627.70 Only covered on permanent
teeth
8337 Root canal obturation - posteriors - each additional canal 186.40
Limited to 2 per beneficiary
8338 Root canal therapy - anterior and premolars - first canal 697.70
per year.
8329 Root canal therapy - anterior and premolars - each additional 233.00
Covered at 100% Transmed
canal
rate and subject to limitations
8339 Root canal therapy - posteriors - first canal 958.70
and DRC protocols. Only
8340 Root canal therapy - posteriors - each additional canal 233.00
stated codes covered.
8334 Re-preparation of previously obturated root canal 148.40
8635 Apexification/recalcification – per visit 133.70
8330 Removal of root canal obstruction 131.20
8136 Access through a prosthetic crown or inlay to facilitate root canal 89.60
treatment
Dentures: Pre-authorisation required
8233 Partial Denture - One tooth 464.60 One per jaw every 4 years for
8234 Partial Denture - Two teeth 464.60 patients older than 21 years.
8235 Partial Denture - Three teeth 695.10 Covered at 100% Transmed
8236 Partial Denture - Four teeth 695.10 rate and subject to limitations
8237 Partial Denture - Five teeth 695.10 and DRC protocols. Denture
8238 Partial Denture - Six teeth 922.00 benefit of R2000.00 per
8239 Partial Denture - Seven teeth 922.00 beneficiary every 4 years.
8240 Partial Denture - Eight teeth 922.00 Excess may be paid from
8241 Partial Denture - Nine teeth and more 922.00 available specialized dentistry
8232 Full upper or lower denture 999.10 benefit of R4000.00 per family
8231 Full upper and lower denture 1620.70 per annum.
8269 Repair Denture 127.50 Once in 365 days per member
8259 Rebase of denture (laboratory) 378.80 Once in 365 days per member
8261 Remodel of denture 608.10 Once in 365 days per member
8263 Reline of denture (selfcuring acrylic) 240.30 Once in 365 days per member
8267 Soft base reline per denture 552.90 Once in 365 days per member
8271 Add tooth to existing partial denture 91.90 Once in 365 days per member
8273 Impression to repair denture 73.60 Once in 365 days
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