Health Benefits provides coverage for dental services to maintain good oral health, prevent cavities and gum disease, and restore function. Seeing an oral health provider regularly can help catch dental problems before they get too serious and require more extensive and expensive procedures. Oral health is directly linked to general health and wellness. Dental infections can make certain conditions - such as diabetes, heart disease, and pregnancy - more complicated.
The dental benefit is administered through a partnership between Health Benefits and PBC. Clients can access detailed information about their dental benefits through the online PBC Member Profile.
Health Benefits covers specific dental items and services under the following categories:
• Bridges; • Crowns, Inlays, Onlays, Veneers;• Dental Surgery;• Dental Sedation;• Dentures;• Exams and X-rays;• Fillings;• Night guards;• Orthodontic Services;• Periodontal Services;• Preventive Services; and• Root Canals and Related Services.
• Crowns, Inlays, Onlays, Veneers;
• Dental Surgery;
• Dental Sedation;
• Exams and X-rays;
• Night guards;
• Orthodontic Services;
• Periodontal Services;
• Preventive Services; and
• Root Canals and Related Services.
Items and services not covered under the dental benefit may be covered on an exceptional basis. Clients should call Health Benefits at 1-855-550-5454 to learn more about exceptional coverage.
• Is the provider registered with PBC for billing?• Is the item or service fully covered by my plan?
Some items and services covered under the dental benefit require approval before oral health providers can bill for them. Providers can submit approval requests directly to PBC. Once they receive authorization, they can provide the item or service and bill PBC directly.
If PBC denies an approval request, clients have the option of appealing the decision. Clients should submit appeals to PBC. More information on appeals can be found on the Appeals page. Clients cannot appeal decisions on items and services that are considered Exclusions.
If clients decide to pay out-of-pocket for an item or service before PBC has authorized an approval request, - or despite PBC denying an approval request - there is the risk they will not be reimbursed.
Oral health providers can identify which items and services require approval and which are covered under the dental benefit by checking their PBC Provider Portal, “PROVIDERnet." If the provider is unable to determine requirements or coverage, the client or oral health provider should contact Health Benefits at 1-855-550-5454.
Some dental items and services are considered Exclusions under the dental benefit. Clients cannot seek exception or appeal for Excluded items. Dental benefit Exclusions include, but are not limited to:
• Cosmetic treatments;• Implants; and• Ridge augmentation.
• Cosmetic treatments;
• Implants; and
• Ridge augmentation.
Dental services must be provided by a licensed oral health professional such as a dentist, denturist, dental therapist, or dental hygienist.
When coverage for a service has been denied, clients have the right to appeal the decision. Items and services that are Exclusions cannot be appealed. See the Appeals page for more information about the appeals process.
Information and forms for oral health providers can be found on the Information for Health Providers page.
For information on how to access dental benefits check out the Dental Benefit Fact Sheet.
1-855-550-5454 (Toll Free)
Download a print version of the FNHA Health Benefits Client Satisfaction Survey
Client Satisfaction Survey FAQs