• Selecting a General Dentist
• Switching Dentists
• Internet Address for DMO Participating Dentist Listing
• Scheduling Appointments
• Simplified Paperwork
• Patient Payments
• Customer Service

1. A retiree must reside, and an active employee must live or work within the DMO Network Service Area to be eligible to enroll in the DMO plan. Please see the Service Area Map (499 KB / 1 page) and County Listings for a complete description of the Service Area.
   
2. Emergency dental care services will be arranged by your selected participating General Dentist for 24-hour emergency treatment. Emergency care is defined as dental services for palliative treatment only (emergency treatment of dental pain). Emergency care is also defined as the dental services administered in a dentist's office, dental clinic, or other comparable facility to evaluate and stabilize dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a prudent layperson, possessing average knowledge of dentistry, to believe that immediate care is needed.
   
   1. What is not considered an emergency?
      Some examples include, but are not limited to the following:
   1. Lost filling
   2. Lost or loose crown or bridge
   3. Broken partial or full dentures
   2. What if you have an emergency?
   1. Contact your selected participating DMO General Dentist, who will arrange for 24-hour emergency coverage.
   2. If your selected participating DMO General Dentist or designated covering dentist is unavailable, contact us at 1-800-275-1794 for guidance or assistance in locating a participating DMO General Dentist for palliative treatment.
   3. If a participating DMO provider is not available, or if you are out of the service area, you will be authorized to seek emergency palliative treatment from any licensed Dentist. You must receive any follow-up treatment from your selected participating DMO General Dentist.

   If you see a dentist who is not participating in the DMO for emergency dental care and obtain prior authorization from the DMO, the services provided for palliative treatment only will be covered at 100% of the usual and prevailing charge, less the applicable patient payments under the Plan. Palliative treatment is defined as emergency treatment of dental pain.
   

3. Complaint procedures have been established to resolve covered member concerns and to settle differences in a fair and timely manner. Aetna's Customer Service Department works to resolve complaints informally with the covered member.
   
   If the results of the informal procedures are unsatisfactory, there is a formal procedure that applies. You may refer to the Complaint / Appeal Procedures for complete details relating to the complaint and appeal process.
   
   The DMO is prohibited from retaliating against any covered member or participating dentist for filing a complaint against the DMO.
   
4. At the time your Group Coverage ends, you and any covered dependents have the right to convert to an Individual DMO Conversion Plan. The application and first premium payment must be received by the DMO within 31 days of termination of Group Coverage. The Individual Conversion Plan will take effect on the day after the Group Dental Care Coverage ends. Please call Aetna Customer Service at 1-800-275-1794 for more information as needed.
   
5. Covered procedures are listed in the "Dental Care Schedule". Plan member payments ("Patient Pays") are required at the time the service is rendered. The patient payments listed apply only when your selected participating General Dentist performs services.
   
   When individual case circumstances or the severity of your condition are such that the Covered Dental Procedure cannot be performed by your selected participating General Dentist, the General Dentist may refer you to a participating Specialty Dentist for care.
   
   
6. When a participating Specialty Dentist performs services, the necessary services will be provided to a Covered Person at 75% of the Specialty Dentist's usual charge. Payment (75% of the usual and prevailing charge) is required at the time the service is rendered.
   
   Specialty Dentists have advanced training in the following types of services:
   
   Endodontics: The diagnosis, prevention and treatment of pathological conditions within the pulp chamber or apical area of a tooth root, including root canal treatment
   Oral Surgery: Surgical procedures in and about the oral cavity and jaws, including extractions
   Periodontics: The examination, diagnosis, and treatment of diseases affecting the tissues that support the teeth
   Orthodontics: The detection, prevention and correction of abnormalities in the positioning of the teeth in their relationship to the jaws, including full braces
   Pedodontics: Children's dentistry
   Prosthodontics: The restoration and maintenance of function by replacement of natural teeth, including crowns, bridges and dentures
   
7. We recommend that prior to starting any dental treatment, you and your selected participating General or Specialty Dentist discuss all charges relative to the services to be rendered.
   
8. You should request a treatment plan from your selected participating dentist, listing each specific service and charge prior to beginning treatment.
   
9. Please take your ID card with you when visiting the dentist. If you have misplaced your card, please call Aetna Customer Service at 1-800-275-1794 to request a replacement.
   
   When canceling a dental appointment, please call at least 24 hours in advance. Your dentist may charge you a fee for broken or missed appointments.
   
10. This plan does not cover all procedures that could be provided by your selected participating General Dentist. You are responsible for the full cost of dental procedures that are performed which are not included on the "Dental Care Schedule". In addition, the "Patient Pays" dollar amount specified for each procedure may not be the only cost you  incur for a given treatment, as the treatment may require more than one dental procedure.
    
11. Exclusions and Limitations:
    
    1. Services that are not reasonably necessary for diagnosis and treatment.
    2. Services not listed in the "Dental Care Schedule"
    3. Treatment for malignancies or neoplasms.
    4. Prescription drugs are not covered by the DMO plan.
    5. A charge for a service not furnished by a Dentist. This does not apply if the service is performed by a licensed dental hygienist under the direction of a Dentist.
    6. A charge for a service to the extent that it is more than the usual charge made by the provider for the same service when there is no coverage.
    7. A charge for a service to the extent that it is above the prevailing charge in the area for dental care of a comparable nature.
    8. A charge for any procedure not performed in a participating General Dentist's or participating Specialty Dentist's office, except for Emergency Care and certain charges for Non-participating Dentists as provided in the Coverage, including but not limited to hospitalization, out-patient centers, IV sedation and general anesthesia.
12. Continuity of Treatment. In the event your selected participating General or Specialty Dentist terminates participation in the DMO and you are currently under active dental treatment, your dentist may continue providing care until the completion of the treatment in progress. In the case of orthodontics begun prior to the participating General or Specialty Dentist's termination, the dentist may continue providing care throughout the course of active orthodontic treatment.

Selecting a General Dentist

You may view a listing of General Dentists participating in your area via the ERS website - www.ers.state.tx.us, "Health & Dental Links," then Aetna DMO (Provider Look-up). Participating dentists are located in most, but not all, areas of Texas. A member shall not be required to travel in excess of 75 miles to obtain covered services from a participating general dentist.

To be selected for the DMO network, dentists must complete our credentialing process and are recredentialed periodically. Each participating general dentist should be able to take care of most of your dental care needs.

You should select a participating General Dentist for yourself and your covered eligible dependents. For your convenience, you may choose a different participating DMO General Dentist for each covered eligible member of your family. You may select a dentist by calling DMO Customer Service at 1-800-275-1794 or you may contact us by e-mail via the ERS website at www.ers.state.tx.us; select "Health & Dental Links", then Aetna Dental Inc. Once you are in the website, select "Customer Service" and follow the prompts. Please remember to contact DMO Customer Service to change providers, not the Employees Retirement System of Texas.

Once enrolled, you and your family will receive family-style DMO ID Cards. Each family ID card displays information for up to four covered family members in a single family. The employee and covered spouse both receive a family-style DMO ID card. Your selected participating General Dentist's name, phone number and the Aetna Customer Service phone number, 1-800-275-1794, are printed on the front of the card.

To be selected for the DMO Network, dentists must complete our credentialing process and are recredentialed periodically. Each participating General Dentist should be able to take care of most of your dental care needs.

• www.ers.state.tx.us

Scheduling Appointments

Once you have selected your participating General Dentist, make an appointment exactly as you would with any other dentist. Please mention that you are covered under the DMO Plan for State of Texas and Higher Education Employees and Retirees (ERS) when you call. At the time of your visit, please show your DMO ID card.

Customer Service

Our Customer Service Department is available to assist you from 8:00 a.m. to 5:30 p.m. Central Time, Monday through Friday. The Customer Service Representatives can answer general questions or address concerns. In addition, these representatives can assist in the selection of a new provider or requests for new ID cards. You can reach Customer Service at 1-800-275-1794. The initial greeting provides access to instructions in either English or Spanish.

If you need a translator, just request one. Aetna Customer Service has access to the AT&T language lines, which provide interpreters in 140 languages.

A telecommunication device (TDD) for the deaf is available at 1-800-234-3730. Operating hours for this service are 8:00 a.m. to 4:30 p.m. Central Time, Monday through Friday.

A computer system provides Aetna Customer Service instant access to your telephone and correspondence history. This eliminates the need for you to repeat your inquiry when speaking with more than one Aetna Customer Service Representative. Since all departments share access to the system, one DMO area can forward information to any other DMO area in a matter of seconds.