2017 Provider Manual
Provider Hotline Number: 086 102 0220
DENTAL
Sum
mar
y of
ben
efits
/ser
vice
s M
edic
al S
chem
e /O
ccup
ation
al
Heal
th P
rodu
ct/I
nsur
ance
Pla
nO
ption
sDe
ntist
ry B
enefi
t
Basi
c De
ntist
ryRa
diol
ogy
(x-r
ays)
Acut
e M
edic
ation
AECI
Med
ical
Aid
Soc
iety
Valu
e O
ption
2 vi
sits p
/b p
er a
nnum
. Spe
cific
cod
esSp
ecifi
c co
des
Acut
e fo
rmul
ary
med
icin
es o
nly
Com
pCar
e W
elln
ess M
edic
al
Sche
me
Net
wor
X; N
etw
orX
ED*
and
Net
wor
X ED
* Pl
us O
ption
s1
visit
p/b
per
ann
um. S
peci
fic c
odes
. Su
bjec
t to
AFB*
*Sp
ecifi
c co
des
Acut
e fo
rmul
ary
med
icin
es o
nly
Mas
smar
t Hea
lth P
lan
Net
wor
k O
ption
2 vi
sits
p/b
per a
nnum
or 4
visi
ts p
/f
per a
nnum
. Spe
cific
cod
es. S
ubje
ct
to A
FB**
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
Esse
ntial
Opti
on1
visit
p/b
per
ann
um. S
peci
fic c
odes
. Su
bjec
t to
OAL
***
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
Tige
r Bra
nds M
edic
al S
chem
eM
zans
i Opti
on1
visit
p/b
per
ann
um. S
peci
fic c
odes
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
Tran
smed
Med
ical
Fun
dSt
ate
Plus
Net
wor
k O
ption
1 vi
sit p
/b p
er a
nnum
. Spe
cific
cod
esSp
ecifi
c co
des
Acut
e fo
rmul
ary
med
icin
es o
nly
Um
vuzo
Hea
lthSt
anda
rd a
nd U
ltra
Affor
dabl
e O
ption
s1
visit
p/b
per
ann
um. S
peci
fic c
odes
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
Uni
vers
al H
ealth
& A
ccid
ent P
lan
(Insu
ranc
e Pl
an)
Opti
on A
, Opti
on A
PLU
S, O
ption
B,
Opti
on B
PLU
S
Emer
genc
y de
ntal
trea
tmen
t onl
y.
Subj
ect t
o ov
eral
l lim
it of
R1
240.
Su
bjec
t to
Stat
ed B
enefi
ts
Subj
ect t
o ov
eral
l lim
it of
R1
240,
su
bjec
t to
Stat
ed B
enefi
tsAc
ute
form
ular
y m
edic
ines
onl
y
Uni
vers
al W
orke
rPla
n (O
ccup
ation
al H
ealth
Pro
duct
)
truV
ALU
E O
ption
No
bene
fitN
o be
nefit
No
bene
fit
truC
ARE,
truH
EALT
H an
d tr
uWEL
LNES
S O
ption
s1
visit
p/e
per
ann
um. S
peci
fic c
odes
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
Witb
ank
Coal
field
s Med
ical
Aid
Sc
hem
eN
tsik
a O
ption
1 vi
sit p
/b p
er a
nnum
. Spe
cific
cod
es.
Lim
ited
to R
1 05
0 pe
r mem
ber a
nd
R2 8
50 p
er fa
mily
Spec
ific
code
sAc
ute
form
ular
y m
edic
ines
onl
y
b =
bene
ficia
ry,
e =
empl
oyee
, ED
* =
Effici
ency
Disc
ount
ed ,
AFB*
* =
Annu
al F
lexi
Ben
efit,
OAL
***
= O
vera
ll An
nual
Lim
it
Dental Provider Manual / 2017
Index1. Introduction 1
1.1. Universal Network – Clients 1
1.2. Identifying members/insured persons/employees 2
2. Benefits and Reimbursement for Dentist 8
2.1. Dental Benefits/Services 8
2.2. Basic dental services – benefit limits 9
2.2.1. All Universal Network Options except Universal Health & Accident Plan 9
2.3. Approved dental procedure codes and reimbursement rates 10
2.3.1. All Universal Network Options except Universal Health & Accident Plan 10
2.3.2. Universal Health & Accident Plan 12
3. Dentures 14
3.1. Benefits available 14
3.2. Approved denture procedure codes and fees 15
4. Specialised Dentistry 15
5. Medicines 16
5.1. Medicine benefits 16
5.2. Universal Dental Network – Medicine Formulary 17
Dental Provider Manual / 2017
1. IntroductionWelcome to the Universal Healthcare Provider Network (“Universal Network”).
Universal Network is the Network Division of Universal Care, an accredited managed care organisation within the Universal Healthcare Group.
Universal Care is contracted to Medical Schemes, Universal WorkerPlan and Universal Health & Accident Plan to establish and manage networks of healthcare providers to service beneficiaries/employees/insured persons in the lower income segments. Our goal is to provide affordable access to primary healthcare, within a provider network arrangement, without compromising the quality of care.
The market the Universal Group is targeting for participation in these network arrangements is not the current existing insured market. The concern of “buy downs” is not only a threat to the Dental Practitioners’ practices but seriously challenges the sustainability of these network arrangements from a funding perspective. Therefore the Universal Provider Network arrangements are definitely not a mechanism to discount the Dental Practitioners’ fee structure but rather a conduit to facilitate access to basic primary healthcare for beneficiaries/employees/insured persons who are currently not covered.
This Manual contains information to assist you, the Dental Practitioner, when servicing beneficiaries/employees/insured persons on any of the medical scheme options, occupational plans and insurance plans using the Universal Provider Network.
Beneficiaries/employees/insured persons may use any dentist on the Universal Network.
1.1. Universal Network – Clients
Name Options
AECI Medical Aid Society Value Option
CompCare Wellness Medical Scheme
NetworX Option
NetworX ED* Option
NetworX ED* PLUS Option
Massmart Health PlanNetwork Option
Essential Option
Tiger Brands Medical Scheme Mzansi Option
Transmed Medical Fund State Plus Network Option
Umvuzo HealthStandard Option
Ultra Affordable Option
Universal Health & Accident Plan(Insurance Plan)
Option A
Option APLUS
Option B
Option BPLUS
Universal WorkerPlan(Occupational Health Product)
truVALUE
truCARE
truHEALTH
truWELLNESS
Witbank Coalfields Medical Aid Scheme Ntsika Option
ED* = Efficiency Discounted
1 Dental Provider Manual / 2017
1.2. Identifying members/insured persons/employees All beneficiaries/employees/insured persons will carry a membership/policy card which will indicate that they are beneficiaries/insured persons/employees on any of the medical scheme options or health plans using the Universal Provider Network.
The following are examples of such cards:
AECI Medical Aid SocietyValue Option:
CompCare Wellness Medical Scheme (Old Cards)NetworX and NetworX Efficiency Discounted Options:
CompCare Wellness Medical Scheme (New Cards)NetworX Option:
NetworX Efficiency Discounted Option:
Dental Provider Manual / 2017 2
NetworX Efficiency Discounted Plus Option:
Massmart Health Plan (Old Cards)Essential and Network Options:
Massmart Health Plan (New Cards)Essential Option:
Network Option:
3 Dental Provider Manual / 2017
Tiger Brands Medical SchemeMzansi Option:
Transmed Medical Fund State Plus Network Option:
Umvuzo HealthStandard Option:
Ultra Affordable Option:
Dental Provider Manual / 2017 4
Universal Health & Accident Plan Option A:
Option APLUS:
Option B:
Option BPLUS:
5 Dental Provider Manual / 2017
Universal WorkerPlan truVALUE Option:
truCARE Option:
truHEALTH Option:
truWELLNESS Options:
Dental Provider Manual / 2017 6
Witbank Coalfields Medical Aid SchemeNtsika Option:
• Confirmation of membership/employee/insured person eligibility can be obtained from:• The Universal Call Centre on (011) 208-1000/1010/1020• The Universal website at: www.universal.co.za
• Service providers are urged to contact the Universal Call Centre to confirm membership/employee/insured person validity and confirm available benefits before providing services to the beneficiary/employee/insured person. Please also check the patient’s details against the patient’s identity book/passport.
7 Dental Provider Manual / 2017
2. Benefits and Reimbursement for DentistsEach Medical Scheme, Occupational Health Product or Insurance Plan on the Universal Provider Network has specific dental benefits which must be obtained from a Universal Network Dental Practitioner (or dental therapist, subject to scope of practice).
2.1. Dental Benefits/ServicesMedical Scheme /Occupational
Health Product/Insurance Plan
Options Basic dentistry
Accidental injury requiring
emergency dental treatment
Specialised dentistry Dentures
AECI Medical Aid Society Value Option
Only PMBs & pre-authorisation required
No benefitOne set p/b every 24 months. Limits apply
CompCare Wellness Medical
Scheme
NetworX; NetworX ED* and NetworX ED* Plus Options
Only PMBs & pre-authorisation required
Only for PMBs and pre-authorisation required. Subject to Annual Flexi Benefit
One set per p/b every 36 months. A 20% co-payment applies.
Massmart Health Plan
Network OptionOnly PMBs & pre-authorisation required
R3 250 p/b orR5 250 p/f. Subject to Annual Flexi Benefit
R3 250 p/b orR5 250 p/f. Subject to Annual Flexi benefit.
Essential OptionOnly PMBs & pre-authorisation required
Only for PMBs and pre-authorisation required
One set of plastic dentures per p/b every 36 months. Applicable to over 21 years of age.
Tiger Brands Medical Scheme Mzansi Option
Pre-authoristion required for 4 or more extractions
Only PMBs & pre-authorisation required
No Benefit
One set of plastic dentures per p/b every 36 months. 20% co-payment applies.
Transmed Medical Fund State Plus Option
Only PMBs & pre-authorisation required
No Benefit
One set of acrylic dentures p/f every 24 months. Limited to R3 160 per partial or full set of dentures.
Umvuzo Health
Standard OptionOnly PMBs & pre-authorisation required
No BenefitOne set p/f every24 months. Limited R2 835 per event
Ultra Affordable Option
Only PMBs & pre-authorisation required
No Benefit No Benefit
Universal Health & Accident Plan (Insurance Plan)
Option A, Option APLUS, Option B
and Option BPLUS
Emergency dental treatment only No benefit No Benefit No Benefit
Universal WorkerPlan
(Occupational Health Product)
truVALUE No Benefit No benefit No Benefit No BenefittruCARE No benefit No Benefit No Benefit
truHEALTH and truWELLNESS No benefit No Benefit
One set of plastic dentures per p/e every 36 months. Applicable to over 21 years of age.
Witbank Coalfields Medical Aid
SchemeNtsika Option
Only PMBs & pre-authorisation required
Only PMBs & pre-authorisation required
One set per p/b every 36 months. A 20% co-payment applies.
b = beneficiary f = familye = employeeED* = Efficiency Discounted
Dental Provider Manual / 2017 8
2.2.
Bas
ic d
enta
l ser
vice
s –
bene
fit li
mits
2.2.
1. A
ll U
nive
rsal
Net
wor
k O
ption
s exc
ept U
nive
rsal
Hea
lth &
Acc
iden
t Pla
n
Dent
al p
roce
dure
s ar
e lim
ited
to th
e lis
t of s
ervi
ce c
odes
as
outli
ned
for e
ach
plan
(for
med
ical
indi
catio
ns o
nly)
Med
ical
Sch
eme
Opti
ons
Annu
al D
enta
l Ex
amin
ation
Prev
enta
tive
Trea
tmen
tRe
stor
ation
s/ C
ompo
site
Fill
ings
Extr
actio
nsO
ral R
adio
grap
hsRo
ot C
anal
Tr
eatm
ent
AECI
Med
ical
Aid
So
ciet
yVa
lue
Opti
on2
p/b
per
annu
m
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Com
pCar
e W
elln
ess M
edic
al
Sche
me
Net
wor
X;
Net
wor
X ED
* an
d N
etw
orX
ED*
Plus
O
ption
s
1 p/
b pe
r an
num
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Mas
sMar
t Hea
lth
Plan
Net
wor
k1
p/b
per
annu
m
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Esse
ntial
1 p/
b pe
r an
num
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Tige
r Bra
nds
Med
ical
Sch
eme
Mza
nsi
1 p/
b pe
r an
num
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Tran
smed
M
edic
al F
und
Stat
e Pl
us
Net
wor
k1
p/b
per
annu
m
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. N
o be
nefit
for w
isdom
teet
h ex
trac
tions
.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Um
vuzo
Hea
lthSt
anda
rd a
nd
Ultr
a Aff
orda
ble
1 p/
b pe
r an
num
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
Uni
vers
al
Wor
kerP
lan
(Occ
upati
onal
He
alth
Pro
duct
)
truV
ALU
EN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fit
truC
ARE,
tr
uHEA
LTH
and
truW
ELLN
ESS
2 p/
e pe
r an
num
Incl
uded
in a
nnua
l de
ntal
exa
min
ation
1
p/e
per a
nnum
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/e
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/e
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/e
pe
r ann
um
Emer
genc
y on
ly
Witb
ank
Coal
field
s M
edic
al A
id
Sche
me
Nts
ika
Opti
on1
p/b
per
annu
m
1 p/
b pe
r ann
umFl
uorid
e tr
eatm
ent:
Age
unde
r 12
year
s on
ly
Pre-
auth
orisa
tion
requ
ired
if >4
per
an
num
p/b
. Onl
y an
terio
r com
posit
e fil
lings
are
cov
ered
.
Pre-
auth
orisa
tion
requ
ired
for 4
or m
ore
extr
actio
ns p
er a
nnum
p/b
. W
isdom
teet
h ex
trac
tions
to b
e do
ne in
de
ntist
’s ro
oms
unde
r loc
al a
naes
thes
ia.
Pre-
auth
orisa
tion
requ
ired
if >2
p/b
pe
r ann
um
Emer
genc
y on
ly
b =
bene
ficia
ry,
e =
empl
oyee
ED
* =
Effici
ency
Disc
ount
ed
9
2.3.
App
rove
d de
ntal
pro
cedu
re c
odes
and
reim
burs
emen
t rat
es2.
3.1.
All
Uni
vers
al N
etw
ork
Opti
ons e
xcep
t Uni
vers
al H
ealth
& A
ccid
ent P
lan
Dent
al p
roce
dure
s ar
e lim
ited
to th
e lis
t of s
ervi
ce c
odes
as
outli
ned
per e
ach
plan
(for
med
ical
indi
catio
ns o
nly)
, sub
ject
to s
cope
of p
racti
ce
Code
Desc
riptio
n
AECI
Med
ical
Ai
d So
ciet
y
Com
pCar
e W
elln
ess M
edic
al
Sche
me
Mas
smar
t He
alth
Pla
n
Tige
r Bra
nds
Med
ical
Sc
hem
e
Tran
smed
M
edic
al
Fund
Um
vuzo
He
alth
Uni
vers
al
Wor
kerP
lan
(Occ
upati
onal
He
alth
Pro
duct
)
Witb
ank
Coal
field
s M
edic
al A
id
Sche
me
Dent
al
Fee
2017
Dent
al
Ther
apis
t Fe
e 20
17Va
lue
Opti
on
Net
wor
X; N
etw
orX
ED*
and
Net
wor
X ED
* Pl
us O
ption
s
Net
wor
k an
d Es
senti
al
Opti
ons
Mza
nsi
Opti
on
Stat
e Pl
us
Net
wor
k O
ption
Stan
dard
an
d U
ltra
Affor
dabl
e O
ption
s
truC
ARE,
tr
uHEA
LTH
and
truW
ELLN
ESS
Nts
ika
Opti
on
8101
Cons
ulta
tion
R206
R107
8104
Lim
ited
oral
exa
min
ation
R100
R83
8107
Intr
a-or
al ra
diog
raph
s, p
er fi
lm (2
with
out
auth
orisa
tion
& 2
with
aut
horis
ation
per
b/
e pe
r yea
r)R8
3R8
0
8109
Infe
ction
Co
ntro
l/bar
rier
tech
niqu
es.
Code
810
9 in
clud
es t
he p
rovi
sion
by t
he
denti
st o
f new
rubb
er g
love
s, m
asks
, etc
., fo
r eac
h b/
e
R18
R18
8110
Ster
ilise
d in
stru
men
tatio
n. T
he u
se o
f th
is co
de is
lim
ited
to a
utoc
lave
d, v
apou
r or
hea
t st
erili
sed
inst
rum
ents
(i.e
. se
ts
of
long
- ha
ndle
d in
stru
men
ts
and/
or
forc
eps)
R48
R48
8112
Intr
aora
l ra
diog
raph
s –
bite
win
g.
per
film
(2
with
out
auth
orisa
tion
& 2
with
au
thor
isatio
n pe
r b/e
per
yea
r)R8
3R8
0
8131
Emer
genc
y de
ntal
trea
tmen
tR1
26R1
07
8132
Root
ca
nal
ther
apy
– gr
oss
pulp
al
debr
idem
ent
R206
−
8133
Re-c
emen
t in
lay,
crow
n or
brid
ge –
per
un
it/ab
utm
ent
R126
−
8145
Loca
l Ana
esth
etic
(1x
per e
vent
)R8
3R1
8
8155
Scal
ing
and
Polis
hing
– co
mpl
ete
denti
tion
(Onc
e a
year
)R1
26R1
02
8159
Scal
ing
and
Polis
hing
(Onc
e a
year
)R2
48R1
87
ED*
= Effi
cien
cy D
iscou
nted
N
ote:
All
fees
are
incl
usiv
e of
VAT
Dental Provider Manual / 2017 10
Code
Desc
riptio
n
AECI
Med
ical
Ai
d So
ciet
y
Com
pCar
e W
elln
ess M
edic
al
Sche
me
Mas
smar
t He
alth
Pla
n
Tige
r Bra
nds
Med
ical
Sc
hem
e
Tran
smed
M
edic
al
Fund
Um
vuzo
He
alth
Uni
vers
al
Wor
kerP
lan
(Occ
upati
onal
He
alth
Pro
duct
)
Witb
ank
Coal
field
s M
edic
al A
id
Sche
me
Dent
al
Fee
2017
Dent
al
Ther
apis
t Fe
e 20
17Va
lue
Opti
on
Net
wor
X; N
etw
orX
ED*
and
Net
wor
X ED
* Pl
us O
ption
s
Net
wor
k an
d Es
senti
al
Opti
ons
Mza
nsi
Opti
on
Stat
e Pl
us
Net
wor
k O
ption
Stan
dard
an
d U
ltra
Affor
dabl
e O
ption
s
truC
ARE,
tr
uHEA
LTH
and
truW
ELLN
ESS
Nts
ika
Opti
on
8161
Topi
cal a
pplic
ation
of fl
uorid
e (o
nce
ever
y 12
mon
ths)
. For
age
und
er 1
2 ye
ars
only
No
bene
fitR1
26R1
02
8163
Fiss
ure
seal
ant,
per
toot
h. F
or a
ge u
nder
12
yea
rs o
nly
No
bene
fitR8
3R7
5
8201
Extr
actio
n,
singl
e to
oth.
Co
de
8201
is
char
ged
for
the
first
ext
racti
on i
n a
quad
rant
R126
R120
8202
Extr
actio
n, e
ach
addi
tiona
l to
oth.
Cod
e 82
02
is ch
arge
d fo
r ea
ch
addi
tiona
l ex
trac
tion
in th
e sa
me
quad
rant
R51
R46
8220
Surg
ical
sut
ures
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitR1
39R1
24
8303
Pulp
cap
ping
, in
dire
ct.
The
perm
anen
t fil
ling
is no
t com
plet
ed a
t the
sam
e vi
sitR1
67R1
52
8307
Ampu
tatio
n of
pul
p (p
ulpo
tom
y)R1
65−
8341
Amal
gam
– o
ne s
urfa
ceR2
50R2
1983
42Am
alga
m –
two
surf
aces
R311
R269
8343
Amal
gam
– th
ree
surf
aces
R377
R330
8344
Amal
gam
– fo
ur a
nd m
ore
surf
aces
R420
R367
8351
Resin
rest
orati
on –
one
sur
face
, ant
erio
rR2
76R2
6583
52Re
sin re
stor
ation
– tw
o su
rfac
es, a
nter
ior
R346
R333
8353
Resin
re
stor
ation
–
thre
e su
rfac
es,
ante
rior
R414
R398
8354
Resin
re
stor
ation
–
four
an
d m
ore
surf
aces
R462
R444
8935
Trea
tmen
t of s
eptic
soc
ket
R92
R77
8937
Surg
ical
rem
oval
of t
ooth
R545
−
8941
Surg
ical
rem
oval
of i
mpa
cted
toot
h –
first
to
oth
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitR9
04−
8943
Surg
ical
rem
oval
of
impa
cted
too
th –
se
cond
toot
hN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
R485
−
8945
Surg
ical
rem
oval
of
impa
cted
too
th –
th
ird a
nd s
ubse
quen
t tee
thN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
No
bene
fitN
o be
nefit
R276
−
ED*
= Effi
cien
cy D
iscou
nted
N
ote:
All
fees
are
incl
usiv
e of
VAT
11 Dental Provider Manual / 2017
2.3.2. Universal Health & Accident Plans
Emergency Dental Events (Stated Benefits and Tariff Codes), subject to overall stated benefit limit of R1 240
The following procedures are reimbursed on the Universal Health & Accident Plans, subject to scope of practice. The reimbursement rates per procedure and acute medicines are in the tables listed below.
• Oral consultations for a specific problem• Oral consultations for a specific problem + pulp removal• Oral consultations for a specific problem + emergency dental treatment• Oral consultations for a specific problem + tooth extraction• Oral consultations for a specific problem + amalgam one surface• Oral consultations for a specific problem + amalgam two surface• Oral consultations for a specific problem + amalgam three surface• Oral consultations for a specific problem + amalgam four surface• Oral consultations for a specific problem + resin one surface, anterior• Oral consultations for a specific problem + resin two surface, anterior• Oral consultations for a specific problem + resin three surface, anterior• Oral consultations for a specific problem + resin four surface, anterior• Oral consultations for a specific problem + surgical removal of erupted tooth
Dental procedure codes Dental Fee 2017 Dental Therapist Fee 2017
1. Limited oral consultation for a specific problem 8104 – Limited oral examination for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R332 R2472. Limited oral consultation for a specific problem + pulp removal8132 - Pulp removal R206 -8104 - Limited oral consultation for a specific problem R100 -8109 - Infection control (gloves) R18 -8110 - Sterilised instruments R48 -8145 - Local anaesthetic per visit R83 -8107 - Intra-oral radiograph (X-ray) R83 - R538 -3. Limited oral consultation for a specific problem + emergency dental treatment8131 - Emergency dental treatment R126 R1078104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R458 R3544. Limited oral consultation for a specific problem + tooth extraction8201 - Extraction, tooth or exposed roots R126 R1208202 - Extraction each additional tooth or exposed roots limit to maximum amount if required R51 R468104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R1878107 - Intra-oral radiograph (X-ray) R83 R808220 - Cost of suture material R139 R1248937 - Sutures R545 - R1 193 R7065. Limited oral consultation for a specific problem + amalgam one surface8341 - Amalgam one surface R250 R2198104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R582 R466
12
6. Limited oral consultation for a specific problem + amalgam two surface8342 - Amalgam two surface R311 R2698104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 RR488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R643 R5167. Limited oral consultation for a specific problem + amalgam three surface8343 - Amalgam three surface R377 R3308104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R709 R5778. Limited oral consultation for a specific problem + amalgam four surface8344 - Amalgam four surface R420 R3678104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R752 R6149. Limited oral consultation for a specific problem + resin one surface, anterior8351 - Resin one surface, anterior R276 R2658104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R608 R51210. Limited oral consultation for a specific problem + resin two surface, anterior8352 - Resin, two surface, anterior R346 R3338104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R678 R58011. Limited oral consultation for a specific problem + resin three surface, anterior8353 - Resin, three surface, anterior R414 R3988104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80 R746 R64512. Limited oral consultation for a specific problem + resin Four surface, anterior8354 - Resin, four surface, anterior R462 R4448104 - Limited oral consultation for a specific problem R100 R838109 - Infection control (gloves) R18 R188110 - Sterilised instruments R48 R488145 - Local anaesthetic per visit R83 R188107 - Intra-oral radiograph (X-ray) R83 R80
R794 R69113. Limited oral consultation for a specific problem + surgical removal of erupted tooth8937 - Surgical removal of erupted tooth R545 -8104 - Limited oral consultation for a specific problem R100 -8109 - Infection control (gloves) R18 -8110 - Sterilised instruments R48 -8145 - Local anaesthetic per visit R83 -8107 - Intra-oral radiograph (X-ray) R83 - R877 -14. Acute Medication R177 -
Dental Provider Manual / 201713
3. Dentures3.1. Benefits availableDentures are limited to the list of benefits as outlined per each plan (for medical indications only).
Medical Scheme /Occupational
Health product/Insurance Plan
Options
Denture Benefit
Plastic dentures Acrylic dentures Benefit Limit
Pre-authorisation
required
AECI Medical Aid Society Value Option
One set p/b every 24 months. For beneficiaries over 21 years
− 100% of Scheme tariff Yes
CompCare Wellness Medical Scheme
Options
NetworX; NetworX ED* and NetworX
ED* Plus
One set p/b every 36 months. For beneficiaries over 21 years
−
80% of cost payable by the scheme and includes professional and laboratory fees. 20% member liability
Yes
Massmart Health Plan
Network Option
Dentures are included in the Specialised Dentistry Limit
Subject to the Annual Flexi Benefit and limited to R3 250 p/b andR5 250 p/f
Yes
Essential Option
One set p/b every 36 months. For beneficiaries over 21 years
− 100% of Scheme tariff Yes
Tiger Brands Medical Scheme Mzansi Option
One set p/b every 36 months. For beneficiaries over 21 years
−
80% of cost payable by the scheme and includes professional and laboratory fees. 20% member liability
Yes
Transmed Medical Fund
State Plus Network Option −
One set p/f every 24 months
Limited to R3 160 per partial or full set of dentures Yes
Umvuzo HealthStandard Option One set p/f every
24 months −100% of agreed tariff includes professional and laboratory fees. Limited to R 2 835 per event
Yes
Ultra Affordable Option No benefit − No Benefit N/A
Universal Health & Accident Plan (Insurance Plan)
Option A, Option APLUS, Option B
and Option BPLUSNo benefit − No Benefit N/A
Universal WorkerPlan
(Occupational Health Product)
truVALUE and truCARE No benefit − No Benefit N/A
truHEALTH and truWELLNESS
One set p/e every 36 months. For employees over 21 years
−
Employee to pay at point of service and claim back from Universal WorkerPlan. Service includes professional and laboratory fees. Employee liable for 20%. Limited to R2 247
Yes
Witbank Coalfields Medical Aid
SchemeNtsika Option
One set p/b every 36 months. For beneficiaries over 21 years
−
80% of cost payable by the scheme and includes professional and laboratory fees. 20% member liability
Yes
b = beneficiary, e = employee, f = familyED* = Efficiency Discounted
Dental Provider Manual / 2017 14
3.2. Approved denture procedure codes and fees
Code Description Denture Code Fee 2017
8231 Complete dentures - maxillary and mandibular R 2 036
8232 Complete dentures – maxillary or mandibular R 1 256
8233 Partial Denture – one tooth R 584
8234 Partial Denture – two teeth R 584
8235 Partial Denture – three teeth R 873
8236 Partial Denture – four teeth R 873
8237 Partial Denture – five teeth R 873
8238 Partial Denture – six teeth R 1 159
8239 Partial Denture – seven teeth R 1 159
8240 Partial Denture – eight teeth R 1 159
8241 Partial Denture – nine or more teeth R 1 159
8259 Re-line complete or partial denture R 476
8269 Repair of/add to denture R 161
8271 Add tooth to existing partial denture R 116
8273 Impression to repair/addition R 92
Listed fees do not include laboratory fees
4. Specialised DentistrySpecialised dentistry is available on:
• CompCare Wellness Medical Scheme: NetworX, NetworX ED* and NetworX ED* Plus Options• Massmart Health Plan: Network Option• Tiger Brands Medical Scheme: Mzansi Option
All specialised dentistry must be pre-authorised by Universal Care.
All dentistry admissions must be pre-authorised by Universal Care, including emergency, urgent and elective procedures/treatments. Only dentistry PMB’s are covered.
Procedures must be authorised at least 48 hours prior to admission and all emergency treatments must be authorised on the first working day after the admission. Failure to pre-authorise, or late authorisations (i.e. not within 48 hours), will result in a co-payment by the member per admission. The value of these co-payments will be determined by the Medical Scheme.
For authorisations: Please contact Universal Care – contact details are on the back cover of this Manual.
Specialised dentistry is not available on:
• AECI Medical Aid Society – Value Option• Massmart – Essential Option• Transmed Medical Fund – State Plus Network Option• Umvuzo Health – Standard and Ultra Affordable Options• Universal Health & Accident Plan• Universal WorkerPlan – truVALUE, truCARE, truHEALTH and truWELLNESS Options• Witbank Coalfields Medical Aid Scheme – Ntsika Option
ED* = Efficiency Discounted
Dental Provider Manual / 201715
5. Medicines5.1. Medicine benefitsIf medicines are required for dental pain or sepsis treatment, the medicines prescribed must be in accordance with the Medicine Formulary and are subject to the Formulary Reference Price (FRP). Only medicines on the formulary will be covered. The medicines can be obtained from a Universal Network pharmacy. See page 17 for the Medicine Formulary.
Medical Scheme Plan/Occupational
Health product/Insurance Plan
Options Acute Medicine Benefit Benefit Limit Formulary Out-of-formulary
medicines
AECI Medical Aid Society Value Option YES Unlimited, if on
formulary YES No Benefit
CompCare Wellness Medical
Scheme
NetworX, NetworX ED* and NetworX ED* Plus Options YES Unlimited, if on
formulary YES No Benefit
Massmart Health Plan
Network Option YES Unlimited, if on formulary YES 25% co-payment
Essential Option YES Unlimited, if on formulary YES 25% co-payment
Tiger Brands Medical Scheme Mzansi Option YES Unlimited, if on
formulary YES No Benefit
Transmed Medical Fund State Plus Network Option YES Unlimited, if on
formulary YES No Benefit
Umvuzo Health
Standard Option YES Unlimited, if on formulary YES No Benefit
Ultra Affordable Option YES Unlimited, if on formulary YES No Benefit
Universal Health & Accident Plan (Insurance Plan)
Option A, Option APLUS, Option B and Option BPLUS YES
Included in the Stated Benefit, subject to overall limit of R1 240
YES No Benefit
Universal WorkerPlan
(Occupational Health Product)
truVALUE No benefit No benefit No benefit No benefit
truCARE, truHEALTHand truWELLNESS YES Unlimited, if on
formulary YES No Benefit
Witbank Coalfields Medical Aid
SchemeNtsika Option YES Unlimited, if on
formulary YES No Benefit
Dental Provider Manual / 2017 16
5.2. Universal Dental Network – Medicine Formulary
Category Therapeutic Description Active Ingredient Example of product name
Infections
Antibiotics - Cephalosporins
Cefaclor
Ceclor 375mg Tab, Vercef 375 mg Tab
Ceclor 187mg/5ml Susp, Vercef 187mg/5ml Susp
Ceclor 375mg/5ml Susp, Vercef 375mg/ 5ml Susp
Cephalexin
Belex 250mg Cap, CPL Alliance Cephalexin 250mg Cap
Belex 500mg Cap, CPL Alliance 500mg Cap
CPL Alliance Cephalexin 125mg/5ml Susp, Ranceph 125mg/5ml Susp
Ranceph 250mg/5ml Susp
Antibiotics - Erythromycin and other macrolides
Azithromycin Varimax 250mg Cap
Zithrogen 500mg Tab
Clarithromycin
Clarihexal 250mg Tab, Klarizon 250mg Tab
Klarithran 500mg MR Tab, Klarizon 500mg Tab
Clarihexal 125mg/5ml Susp, Simayla Clarithromycin 125mg/5ml Susp
Clarihexal 250mg/5ml Susp, Simayla Clarithromycin 250mg/ml Susp
Erythromycin Estolate
Purmycin Cap, Spectrasone Cap
Purmycin 125mg/5ml Susp
Spectrasone 250mg/5ml Susp
Erythromycin Stearate Betamycin Tab, Eryko Tab
Antibiotics - Other agents Clindamycin Dalacin C Cap
Antibiotics - Penicillins
Amoxicillin
Allmox 250mg Cap, Auro amoxicillin 250mg Cap, Moxan 250mg Cap
Allmox 500mg Cap, Auro amoxicillin 500mg Cap, Moxan 500mg Cap
Allmox S 125mg/5ml Susp, Moxypen 125mg/5ml Susp
Allmox SF 250mg/5ml Susp, Moxypen 250mg Susp
Amoxicillin + Floxacillin Macropen Susp
Macropen Cap
Amoxicillin + K Clavulanate
Amoclan 375mg Tab, Sandoz Co Amoclav 375mg Tab
Amoclan 625mg Tab, Sandoz Co Amoclav 625mg Tab
Amoclan 100mg Tab, Sandoz Co Amoclav 1000mg Tab
Amoclan 125mg/5ml Susp, Sandoz Co Amoclav S 125mg/5ml Susp
Amoclan SF 250mg/5ml Susp, Sandoz Co Amoclav SF 250mg/5ml Susp
Sandoz Co Amoclav BD 457mg/5ml Susp
Cloxacillin Cloxin 250mg Cap
Cloxin 500mg Cap
Penicillin V Potassium Betapen 250mg Tab
Betapen 125mg/5ml Syr
Antibiotics - Quinolones Ciprofloxacin
Cilofloc 250mg Tab, Ciploxx 250mg Tab
Cilofloc 500mg Tablets, Ciprogen 500mg Tab
Austell Ciproflox 750mg Tab, Cifloc 750mg Tab
17 Dental Provider Manual / 2017
Category Therapeutic Description Active Ingredient Example of product name
Infections
Antibiotics – Sulphonamides & combinations
Sulphamethoxazole + Trimethoprim
Cozole 400/80mg Tab, Purbac 400/80mg Tab
Sandoz Co-Trimoxazole 800/160mg Tab, Purbac DS 800/160mg Tab
Co-trim Susp, Cozole Susp
Antibiotics - TetracyclinesDoxycycline
Cyclidox EC 50mg Cap
Doxycyl 100mg Cap
Oxytetracycline Be-Oxytet 250mg Cap
Anti-fungal agents Fluconazole
Mylan Fluconazole 50mg Cap
Aspen Fluconazole 150mg Cap, Fluzol 150mg Cap
Diflucan 50mg/5ml Susp
Diflucan 200mg/5ml Susp
Antimicrobial - Anaerobic and antiprotozoal agents Metronidazole
Acuzole 200mg Tab, Amzole 200mg Tab
Acuzole 400mg Tab, Amzole 400mg Tab
Flagyl Susp
Inflammation Non-Steroidal Anti-inflammatories (NSAIDs)
Ibuprofen
Betagesic 400mg Tab, Ibumax 400mg Tab, Inza 400mg Tab
Betagesic 200mg Tab, Ibumax 200mg Tab, Inza 200mg Tab
Ibugesic Susp, Ibumax Susp
Meloxicam Flexocam 7.5mg Tab, Medoxicam 7.5mg Tab
Naproxen Napflam 250mg Tab, Naproscript 250mg Tab,
Napflam 500mg Tab, Naproscript 500mg Tab
Local anaesthetics and
antiseptics
Mouth and throat preparations
Benzocaine Trochain Loz, Orocaine Loz
Chlorhexidine Gluconate
Corsodyl Soln, Corsodyl Soln Mint
Povidone + Iodine Septadine Oral Antiseptic, Dermadine Gargle
Tetracaine Dynexan Oint
Pain
Analgesics - combination
Paracetamol + Codeine + Caffeine + Meprobamate
Go-Pain Tab, Painagon Tab
Paracetamol + Codeine Spectrapain Cap
Adco-Napacod Tab , Codorol Tab, Empacod Tab, Painamol Plus Tab
Paracetamol + Promethazine + Codeine
Ban Pain Syr, Painagon Syr, Stilpane Syr
Analgesics - plain
Aspirin Bayer Aspirin 300mg Tab
Paracetamol
Gulf Paracetamol mg Tab Paingesic Tab, Zydus-Paracetamol Tab
Adco-Paracetamol Syr, Go-Pain P Syr, Painamol Syr
Empaped 125mg Supp
Empaped 250mg Supp
Dental Provider Manual / 2017 18
Notes
19 Dental Provider Manual / 2017
Notes
Dental Provider Manual / 2017 20
Universal Healthcare Provider NetworkTel: +27 11 208 1000/1010/1020 / Fax: +27 11 807 4496
Email: Claims queries: [email protected] / Provider Network queries: [email protected]: www.universal.co.za
Universal HealthcareUniversal House, 15 Tambach Road, Sunninghill Park, Sandton / PO Box 1411, Rivonia, 2128
Dental AuthorisationsAECI Medical Aid Society – 0861 234 007 / CompCare Wellness Medical Scheme – 0861 222 777
Massmart Health Plan – 0860 002 117 / Tiger Brands Medical Scheme – 0800 002 636Transmed Medical Fund – 0861 686 278 / Umvuzo Health – 0861 728 737