Superior Officers Council City of New York Police Department

Retired Member Dental Benefit

Empire Reimbursement

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Who is Covered

All members of the Superior Officers Council and their eligible dependents are covered under our Dental Benefits Program.

Eligible dependents include the member's spouse (unless legally separated); all unmarried children under age 19 and unmarried dependent children between 19 and 23 years of age who are full time students in an institution of higher education. Also covered are registered domestic partners and any physically handicapped or mentally retarded child of any age who became so handicapped prior to age 19, and who is unmarried, chiefly dependent upon the SOC member for support and incapable of self-sustaining employment because of the handicap.

How to Claim Benefits

When you know it will be necessary for you or an eligible dependent to be treated by a dentist, or in a situation where emergency treatment was performed, you can download a claim form by clicking on the link at the top of this page or by calling the SOC Office. You must complete the patient's portion of the form and the dentist completes the remainder of the form or attaches a standard office generated printout. It is important that the SOC Member's social security number be included on the form as it serves as an identification number.

The completed form(s) should then be returned by the member to the SOC office for determination of eligibility and benefit authorization. Upon authorization the SOC will forward the form to Healthplex for processing. Processing and/or payment can take up to 6 weeks. Reimbursement checks are issued directly to the member.

Pre-Determination of Benefits
(Pre-Certification)

Pre-Determination of benefits is required for: space maintainers, inlays and restorative crowns as well as all endodontic, periodontic, prosthetic and orthodontic services. This system has been instituted to assure members of our group of quality dental care, and to notify the dentist of the services covered under our program.

The pre-determination procedure requires that your dentist fill out a regular claim form as a "Treatment Plan" before treatment has begun.

Be sure the dentist includes the patient's x-rays. This will reduce the processing time. The treatment plan and x-rays should be sent to the SOC, which will then forward them to Empire.

Empire will process the treatment plan and the dentist will receive a pre-determination form which will show these services that are covered by our program. Services not covered will be indicated on the form. When treatment is completed the dentist must insert the dates the authorized services were performed and return the pre-determination form for payment.

All claim forms received are screened for completeness, numbered, checked for eligibility, reviewed for coverage and approved or rejected. Both you and, in most instances, your dentist are advised of the approval or rejection of benefits. Benefits for covered services will not be paid directly to the dentist. Plan allowances will be paid to the member is responsible for the dentist's full charges.

Claim Review Procedure

If you disagree with the disposition of a claim, you may request a review. You, or your duly authorized representative, must make the request in writing within 60 days and forward it to: Empire Blue Cross Blue Shield Claims Review, P.O. Box 79, Minneapolis, MN.

Be sure to include your current identification number and the claim number as well as any pertinent information or comments you wish to make. Upon receipt of the request for review, the claim will then be reconsidered taking into account any additional materials you have provided. Upon completion of this review, you will receive written notification of the decision, explaining the basis for upholding or modifying the original disposition of the claim.

Non-Duplication of Benefits

If a member or eligible dependent is entitled to additional benefits for services covered under our dental program through any other source (excluding an individual insurance policy), the benefits available under this program may be reduced so that the total of benefits received through all sources will not exceed 100 percent of the actual charges incurred for covered dental services.

Services Not Covered

Our dental benefits program does not provide benefits for:

• Dental services received form a dental or medical department maintained by or on behalf of an employer
• a mutual benefit association, labor union, trustee, or similar person or group
• dental services for which the subscriber incurs no charge
• dental services for which coverage is available to the subscriber, in whole or in part, under any Worker's Compensation Law or similar legislation whether or not the subscriber claims compensation or receives benefits there under and whether or not any recovery is had by the subscriber against a third party for damages resulting from a condition, disease, ailment or accidental injury necessitating dental services
• dental service with respect to congenital malformations or primarily for cosmetic or esthetic purposes
• dental services furnished or available to a subscriber in whole or in part under the laws of the United States (except for Medicaid), or any state or political subdivision thereof, or for which the subscriber would have no legal obligation to pay in the absence of this or any similar coverage
• dental services to the extent coverage is available to the subscriber under any other contract of a participating plan
• dental services to the extent that charges for such services exceed the charge that would have been made and actually collected if no coverage existed hereunder
• gold foil restorations
• dental services not considered within the scope of normal good dental practice or which are inconsistent with the highest ethical standards of the dental profession
• fissure sealants
• bacteriological examinations
• dental services other than those specifically listed as covered dental services
• loss or theft of dentures or appliances
• replacements and/or repair of any appliances furnished under the orthodontic treatment plan
• prosthetic services where teeth are restorable by means other than crowns
• services involving periodontal, provisional, or temporary splints
• temporary crowns, occlusal adjustments, appliances or restorations used solely to increase vertical dimensions
• bridges or dentures involving implants

No benefit will be paid under this contract for any loss, or portion thereof, for which mandatory automobile no fault benefits are recoverable or recovered.

Payments of benefits for replacement of full or partial dentures, inlays, crowns, and bridges shall be limited to once every five years.

Orthodontia is not covered under any circumstances for the member, spouse, or dependent children.

Missing Tooth

In order for a tooth or teeth to be eligible for replacement, the teeth must have either been extracted or have been replaced by a fixed or removable appliance during the time you were eligible for benefits under your group coverage.

Alternate Benefits

When there is a choice between two professional acceptable procedures, both of which will achieve the same results, for the replacement of missing teeth or the restoration of teeth, benefits will be provided for the less expensive procedure.

If you have any questions concerning this program, you can call: Empire, Inc. Customer Service (800) 722-8879 and give the group number 280106