Dental Benefits and Rules

General Information
TopMed provides a comprehensive set of Dental Benefits, payable from your Major Medical Benefit (where applicable) on the Traditional Option, Incentive Savings and Incentive Comprehensive Options (See Summary of Benefits for the benefits and limitations provided per option).

Benefits are payable at 80% of the TT on the TopMed Traditional Option and 75% of the TT in respect of the Incentive Savings and Incentive Comprehensive Options, which is applicable to all your Dental Benefits, including hospitalisation (where clinically approved). Should your dentist charge above the TT, you will be liable for the applicable co-payment as well as the difference between the TT and the fees that your dentist charges. However, it is your right to negotiate this difference with your dentist, to minimise your out-of-pocket payment.

Benefits payable
For information on the benefits provided refer to the Summary of Benefits per option, which will outline the benefits provided per option.

Conservative Dentistry
The benefits provided as part of your Conservative Dentistry are highlighted in the Summary of Benefits.

Specialised Dentistry and Hospitalisation
The provision of Specialised Dentistry and Hospitalisation benefits are based on clinical criteria, subject to obtaining pre-authorisation (PAR) from TopMed, prior to treatment being received.

If no PAR is obtained or if a PAR is obtained late, no benefits will be paid by TopMed. Refer to member guide for additional information on obtaining pre- authorisation.

As part of the pre-authorisation process please be advised that treatment plans/tooth numbers/x-rays etc will be required for certain Specialised Dentistry benefits. In addition, all requests for hospitalisation will require letters of motivation together with the relevant radiographs from your dentist before any procedures will be authorised.

Call 0860 00 21 58 to obtain a PAR.

General Benefit Exclusion Summary
List of dental exclusions can be found on page 20 of member guide

Dental Claims
All dental claims must be submitted to TopMed
PO Box 2338
Durban
4000

When submitting a claim, please ensure the following details are clearly visible:
• Your membership number
• The dentist’s details and practice registration number
• The correct dependant code (see your membership card)
• The treatment date