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COMBINED DESCRIPTION OF SERVICES AND DISCLOSURE FORM



DEDICATED DENTAL SYSTEMS, INC.

Individual Contract, Evidence of Coverage and Disclosure Form (Individual Contract)

For Members of Dedicated Dental Systems, Inc. Individual and Family Dental Plan

Please retain this booklet as it contains important information regarding your dental coverage.

This Combined Evidence of Coverage and Disclosure Form completely describes the plan and your rights under the plan, and if you choose to enroll it is your contract with Dedicated Dental Systems, Inc. (the Plan). If you have any questions about this Description please call the Plan by phone at (800) 277-1112 or in writing at the address listed below:

Dedicated Dental Systems, Inc.
9800 La Cienega Blvd., Suite 800
Inglewood, CA 90301
(800) 277-1112
Fax: (866) 647-0699
www.Dedicated-Dental.com

This Individual Contract is subject to Chapter 2.2 of Division 2 of the California Health and Safety Code (the Knox-Keene Act) and the regulations issued by the Department of Managed Health Care. Should either the law or the regulations be amended, such amendments shall automatically be deemed to be a part of this document and shall take precedence over any inconsistent provision. Any provision required in this Evidence of Coverage and Disclosure Statement by either law or the regulation shall automatically bind the Plan.

TABLE OF CONTENTS

Using this Booklet
Welcome! About the Dental Plan
Multilingual Services
Service Area
Member Identification Card
Dependent Coverage
When Coverage Begins
Premiums/Prepayment Fees
Enrollment
Access to Care – Physical Limitations
Access for the Hearing Impaired
The Americans with Disabilities Act of 1990
Interpreter Services
Covered Services
Choice of Dentists
Office Hours and Emergency Services
Choosing a General Dentist Dental Provider
Scheduling Appointments
Timely Access to Care
Changing Your Provider
Other Charges
Member Liabilities
Emergency Services
How to Receive Reimbursement
Non-Qualifying Services
What to Do If You Are Not Sure If You Have an Emergency
Non-Covered Services
Care following Emergency Services
Referrals to Specialists
Treatment Authorizations
Obtaining a Second Opinion
Continuity of Care for New Members
Continuity of Care for Termination of Provider
Cancellation of Benefits
Disenrollment
Renewal Provisions
Cancellation of Servfices
Processing and Enrollment Fees
Reinstatement
Member Rights and Responsibilities
Confidentiality of Medical Record
Grievance and Appeals Process
Review by the Department of Managed Health Care
Binding Arbitration
Dual Coverage
Third Party Recovery Process and Member Responsibilities
Non-Duplication of Benefits with Workers’ Compensation
Reimbursement Provisions – If You Receive a Bill
Public Participation and Policy
Notifying You of Changes in the Plan
Organ and Tissue Donation
Definitions
Limitations
Exclusions
Orthodontic Benefit Limitations and Exclusions
Schedule of Benefits

INTRODUCTION


USING THIS BOOKLET

This booklet, called the Individual Contract, contains detailed information about the Plan Program benefits, how to access benefits, and the rights and responsibilities of Plan Members. Please read this booklet carefully and keep it on hand for future reference.

WELCOME! ABOUT THE DENTAL PLAN

Welcome to Dedicated Dental Systems, Inc. (the Plan)! The Plan appreciates your enrollment and looks forward to servicing your dental needs. The Plan arranges for dental services by contracting with Participating Dentists to provide services to enrolled Members. We encourage you to take an active role to ensure good dental health. Most importantly, we encourage you to use your benefits and we recommend scheduling a first appointment with a General Dentist within 120 days of enrollment. This Evidence of Coverage will help you understand the dental plan benefits. If you have questions about Benefits, Copayments, Limitations, or Exclusions, you may call the Plan’s Member Service Department (800) 277-1112. Normal business hours are Monday-Friday, 8:00 AM to 6:00 PM.

MULTILINGUAL SERVICES

If you or your representative prefer to speak in any language other than English, call us at (800) 277-1112; TDD/TTY for the hearing impaired at (877) 688-9891 to speak with a Plan Member Services Representative; or the California Relay Service at (800) 735-2929. Member Services can help you find a dentist who speaks your language or who has a regular interpreter available. You do not have to use family members or friends as interpreters. If you cannot locate a dentist who meets your language needs, you can request to have an interpreter available for discussions of medical information at no charge.

This EOC/DF booklet, as well as other informational material, has been translated into Spanish. To request translated materials, please call the Plan Member Services at (800) 277-1112; TDD/TTY for the hearing impaired at (877) 688-9891 or the California Relay Service at (800) 735-2929.

SERVICE AREA

To enroll and remain enrolled in the Dedicated Dental Plan, you and your dependents must live or work in the Service Area, which means those geographic areas of California which the Department of Managed Health Care has approved for coverage by the Plan. The geographic areas includes all the population centers in Kern County to the Los Angeles border on the south, Kings, Tulare and Inyo Counties’ borders on the North, San Bernardino County border on the east, and San Luis Obispo County border on the West. The zip codes in Alameda County, Santa Clara County, San Francisco County, San Mateo County, Sonoma County, San Joaquin County, Orange County, Riverside County, San Bernardino County, Los Angeles County, Santa Barbara County and San Diego County that the dental plan, to which a member is assigned, serves. If you move out of Dedicated Dentals Service Area, You must inform Dedicated Dental by calling Member Services at 1-800-277-1112 and request a transfer to another participating plan provider that serves the service area in which you will reside thirty (30) days prior to the move.

MEMBER IDENTIFICATION CARD

All Members of the Plan are given a Member Identification card that contains important information regarding their dental benefits. If you have not received or if you have lost your Member Identification card, please call the Plan Member Services at (800) 277-1112; TDD/TTY for the hearing impaired at (877) 688-9891 or the California Relay Service at (800) 735- 2929), or the California Relay Service at (800) 735-2929. To receive dental care, please show your Plan card to your provider.

DEPENDENT COVERAGE

The Plan membership can be purchased by an Individual or Family. The following describes the standard eligibility provisions under this dental plan. If you meet these requirements and live or work in the Service Area, you may enroll in this dental plan. The following conditions describe those Family Members usually eligible to join the Plan:
  1. The Subscriber’s lawful spouse or Life Partner
  2. A person of the same or opposite sex who:
    Shares your permanent residence;
    Has resided with you for no less than one year;
    Is no less than eighteen years of age
  3. An unmarried, natural born or legally adopted child of the subscriber, spouse or life partner, under 26 years of age.
  4. An unmarried, natural born or legally adopted child of the subscriber, spouse or life partner who has reached 26 years of age may continue to be covered until the end of the month in which the child’s 26th birthday occurs if the child qualifies as yours, your spouse’s or life partner’s dependent under Internal Revenue Service standards AND is enrolled as a full-time student in an accredited college or university
  5. An unmarried, natural born or legally adopted child of the Subscriber, spouse or life partner who has been enrolled in this dental plan prior to reaching 26 years of age, or 26 years of age in the case of a full-time student described above.
  6. Your dependent children regardless of age who are a) incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness, or condition (proof of disability is required) and b) chiefly dependent upon the subscriber for support and maintenance.
Coverage may be continued as long as the disability and dependency exist.

The plan shall send notification to the subscriber at least 90 days prior to the date the child attains the limiting age described in the above paragraph. Dependent child's coverage will terminate upon attainment of the limiting age unless the subscriber submits proof of the criteria described above to the plan within 60 days of the date of receipt of the notification. Upon receipt of a request by the subscriber for continued coverage of the child and proof of the criteria described in the above paragraph, the plan shall determine whether the child meets that criteria before the child attains the limiting age. If the plan fails to make the determination by that date, it shall continue coverage of the child pending its determination.

WHEN COVERAGE BEGINS

The following provides a description of the standard commencement of coverage provisions.
  • Instant Coverage! Your benefits are effective as soon as Dedicated Dental receives your signed application and payment.
  • For Subscribers and Family Members becoming enrolled subsequent to the effective date of this dental plan, coverage will begin on the first day of the month following the processing of a change in the enrollment in the plan.
  • For children born to or adopted by subscriber, spouse or life partner after coverage commences, coverage will be effective at date of birth or date physical custody begins, respectively. Coverage shall continue for only 30 days thereafter, unless you complete the enrollment process for the child within 30 days of such dates, in which case coverage shall continue beyond this 30-day period.
  • For other Family Members who become eligible after coverage commences (e.g., by marriage), coverage begins on the first of the month after you apply for enrollment as long as the application is made within 31 days of the date they become eligible.

PREMIUMS/PREPAYMENT FEES

You are responsible to pay any enrollment and premium payments to participate in this plan. You may obtain information regarding Premium/Prepayment Fees and any necessary bank, or credit card payments by contacting the Plan Member Services at (800) 277-1112 for assistance.

ENROLLMENT

If a Subscriber or Family Member(s) does not enroll when first eligible, they may not be eligible to be added to an existing contract until the renewal period. If your coverage is terminated by the Plan for cause (such as misuse of your identification card or inappropriate use of Covered Services), your application for re-enrollment will not be accepted.
ENDING COVERAGE (TERMINATION OF BENEFITS) Coverage will end at 11:59 PM on the day determined by the Plan as to the termination of benefits.

ACCESS TO CARE

PHYSICAL LIMITATIONS

The Plan has made every effort to ensure that the dental offices are accessible to the disabled. If you are not able to locate a provider that can accommodate your needs, please contact the Plan Member Services at (800) 277-1112 for assistance.

ACCESS FOR THE HEARING IMPAIRED

The hearing impaired may contact us through our TDD number at (877) 688-9891 Monday through Thursday, from 8:00 AM to 5:00 PM and 8:00 AM to 4:30 PM Friday. Between 5:00 PM (4:30 PM on Friday) and 8:00 AM and on weekends, please call the California Relay Service/TTY at (800) 735-2929 to get the help you need.

THE AMERICAN WITH DISABILITIES ACT OF 1990

The Plan will not discriminate against any enrollee, applicant for employment or other party because of race, religion, color, sex, age, marital status, handicap status, veteran status or national origin and agrees that to the extent this contract is applicable, and the Plan will comply with all applicable provisions and requirements of Executive Order 11246 as amended by Executive Order 11375 setting forth the rules, regulations and relevant orders of the Secretary of Labor as well as California Statutes 12940 (Non- Discrimination in Employment), 12945 (Pregnancy Leave Non-Discrimination), and Section 504 of the Federal Rehabilitation Act of 1973 (Non-Discrimination of Handicap).

INTERPRETER SERVICES

Interpreter services will be coordinated with scheduled appointments to ensure availability at the time of the dental appointment. Please contact Member Services Department to schedule an appointment at (800) 277-1112.

COVERED SERVICES

The dental services and procedures listed in the Schedule of Benefits are available at the listed copayments when necessary for your dental health in accordance with professionally recognized standards of practice, subject to the limitations and exclusions described for each category and for all services. Please see the Schedule of Benefits for a list of specific covered dental procedures, copayments, exclusions and limitations associated with your plan.

CHOICE OF DENTISTS

Please read the following information so you will know how to access services from participating dentists.

OFFICE HOURS AND EMERGENCY SERVICES

The Plan offers general services in a variety of locations within the service area. Your Network Dentist will be open during normal work hours, Monday through Friday. Detailed information regarding the services available, network locations and hours of Plan Providers, may be obtained by calling the Plan’s administrative office at (800) 277-1112. In the event of any emergency, call your Network Dentist and you will be told what to do. Your Network Dentist will arrange for emergency dental care, emergency service is provided 24 hours a day, 7 days per week. You can also call the Plan at (800) 277-1112 for assistance with after-hours care.

CHOOSING A GENERAL DENTIST DENTAL PROVIDER

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHO OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED:

To access services, you must choose a primary care General Dentist from the Plan Participating Dentist Directory. Plan Member Services staff is available to provide assistance in your selection of a primary care General Dentist. We request that you select your General Dentist at the time when you submit the Enrollment form to the Plan. If a General Dentist is not chosen, the Plan will assign one that is near your residence. Except as specified below, Covered Services must be provided by your primary care General Dentist to be covered under this dental plan. The Plan providers are compensated by enrollees through copayments required for treatment received. Provider compensation is based solely on enrollee payments. The Plan does not offer Providers any additional financial incentives, bonuses or compensation to deny, reduce limit or delay appropriate treatment. This dental plan does not cover products, services and supplies provided by a dentist who is not your General Dentist, except as specifically described under the section titled Emergency and Urgent Care Services and Referrals to Specialists in this Individual Contract. Your General Dentist must obtain approval from the Plan prior to referral to a specialist. This Plan does not cover any specialty dental services performed by non-contracting dental specialists, except for the aforementioned orthodontic services. If you wish to know more about these issues, you may contact the plan member services department at (800) 277-1112.

ASSIGNMENTS

There is no restriction on the assignments of any sums due Subscribers by the Plan.

SCHEDULING APPOINTMENTS

To schedule an appointment, please contact your primary care General Dentist directly. The phone number for the General Dentist that you chose is located on your identification card. If your identification card is not available, you may contact the Plan Member Services at (800) 277-1112 for assistance. If you need to change an appointment that is scheduled with your General Dentist, please contact the dental office directly.

TIMELY ACCESS TO CARE

The dentists that participate in the Plan’s network will provide dental care services in a timely manner that is appropriate for the nature of your dental care needs consistent with good professional practice standards.
  • Urgent appointments will be offered within 24 hours of the time of the request for appointment, when consistent with the individual enrollee’s needs and as required by professional recognized standards of dental practice;
  • Non-urgent appointments will be offered within 36 business days of the request for the appointment;
  • Preventive dental care appointments shall be offered within 40 days of the request for appointment.

If you need to contact your dentist for emergency services outside of standard business hours, the office will utilize an answering service or machine that provides instructions regarding how enrollees may obtain urgent or emergency care including when applicable, how to contact another provider who has agreed to be on-call to triage by phone, or if needed, deliver urgent or emergency care services. You may contact the Plan Member Services at (800) 277-1112 if you need assistance with triage and screening services, or if you believe that you are not receiving timely access to covered services.

CHANGING YOUR PROVIDER

You may change your dentist as often as once a month, if needed, by contacting the Plan Member Services at (800) 277-1112. All changes should be requested by the 20th of any month for a change that will take effect on the 1st of the next month (for example, if you contact the Plan Member Services on the 15th of July to change your dental office, your will be effective in the new office on August 1st. If you contact the Plan Member Services on the 25th of July to change your dental office, you will be effective in the new office on September 1st). Until the change takes effect, your currently assigned dental office is responsible for your care. Your change of a General Dentist won’t affect access to other providers.

At times, the Plan may find it necessary to change your selected General Dentist. This may happen, for example, if you chose a dentist that is no longer participating in the plan. If this happens, the Plan will notify you in writing of the change of primary care General Dentists. For continuity of care, the Plan will assign you to another primary care General Dentist that is close to your home. You may always contact the Plan Member Services at (800) 277-1112 to change again if the selection the Plan made for you is not convenient.

OTHER CHARGES (CO-PAYMENTS)

You will be required to pay a copayment fee directly to the dentist at the time of service for some services. Copayments are listed in the Schedule of Benefits- Covered Dental Services section of this Individual Contract-Combined Evidence of Coverage and Disclosure form.

MEMBER LIABILITIES

In addition to the copayments for selected services, you must pay for any non-covered dental services that you choose to have done. Often there are several choices or different approaches that a dentist may take to treat dental conditions. This program is designed to cover dental treatment using the most cost effective option that is consistent with good professional practice. If you chose a more costly or an optional alternative, you will be responsible for all charges in excess of the covered dental benefit.

Your dentist may charge you a fee if you fail to cancel an appointment at least 24 hours prior to the appointment. This fee may be waived if it was not reasonably possible for you to cancel your appointment.

In the event the Plan does not pay a participating provider for contracted rates, you will not be liable to the provider for any money owed by the Plan. In the event that the Plan fails to pay a non-participating provider, you may be liable to the non-participating provider for the costs of services rendered.

EMERGENCY SERVICES

The Plan will pay up to a maximum of $50.00 per agreement year, per Member for out-of-area emergency services rendered to Subscribers and/or Members who require such services when they are more than thirty (30) miles or minutes away from a Plan Provider. Subscribers and/or Members can determine whether they are more than thirty (30) miles or minutes away from a Plan provider by telephoning the Plan's administrative office. If the Subscriber and/or Member are unable to contact the Plan prior to obtaining such services, the Members must notify the Plan within seventy-two (72) hours or as soon as possible after receipt of such services. These procedures should also be followed for in area emergency services described below:

An emergency is a dental condition, including severe pain, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
  • Placing the Member’s dental health in serious jeopardy, or
  • Causing serious impairment to the Member’s dental functions, or
  • Causing serious dysfunction of any of the Member’s bodily organs or parts.

Emergency dental care services are available to you twenty-four (24) hours a day, both inside and outside our service area. You should seek emergency dental care for relief of pain when you have a dental condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate treatment could seriously jeopardize your health or impair your dental functions.

If you have a dental emergency, immediately contact your selected General Dentist for an appointment. All participating dentists will have Emergency Dental Care available 24 hours a day, 7 days a week. You may also contact the Plan at (800) 277-1112 for assistance. If the Participating Provider is not available, you may seek Emergency Dental Care from any licensed dentist. Services provided by a dentist other than your General Dentist will be covered only when it is shown that:

  • You were unable to get services from your General Dentist.
  • Services were for Emergency Dental Care.
  • Services were Medically Necessary.
  • Services are listed as covered benefits under this plan.
You must pay any applicable plan copayments for services that you receive. If the above conditions are not met, you will need to pay all billed charges at the dentist’s Usual Fee.

HOW TO RECEIVE REIMBURSEMENT

The Plan will reimburse Subscribers and/or Members for such services upon presentation by the Subscriber and/or Member of a copy of the bill or receipt from the treating dentist. The Subscriber and/or Member must provide such evidence within thirty (30) days of receipt of emergency treatment.

The claims will be acted upon within thirty (30) days after receipt by the Plan unless additional information is required. Upon receipt by the Plan of such additional information, the claim will be granted or denied, either partially or completely, within thirty (30) days. If the claim is denied or partially denied, the Subscriber and/or Member will receive written notification of the decision, including the specific reasons for the denial of the claim, a reference to the pertinent Plan provision on which the denial is based, and notice that the Subscriber and/or Member may request reconsideration of the denial by filing a written notice with the Plan within one (1) year after receiving notice of the denial. Reconsideration will be made by the Dental Director through the Plan’s grievance process. Enrollees whose claim has been denied are also entitled to dispute the denial through the Independent Medical Review (IMR) process. The IMR process is explained more fully, under Grievance and Appeals Process.

NON-QUALIFYING SERVICES

Emergency Dental Care does not include these services:
  • Normal diagnostic and preventive services.
  • Permanent restorative and prosthetic services.
  • Complete endodontic services.
  • Complete periodontal services.
  • Orthodontic services.
  • Oral surgery for conditions that is not severe.
  • Other services not required for Emergency Dental Care.

WHAT TO DO IF YOU ARE NO SURE IF YOU HAVE AN EMERGENCY

If you are not sure whether you have an emergency or require urgent care, please contact your General Dentist to explain your situation. All participating dentists will have Emergency Dental Care available 24 hours a day, 7 days a week. You may also contact the Plan at (800) 277-1112 for assistance.

NON-COVERED SERVICES

The Plan does not cover dental services that are received in an emergency or urgent care setting for conditions that are not emergencies or urgent if you reasonably should have known that an emergency or urgent care situation did not exist. You will be responsible for all charges related to these services.

IMPORTANT:

If you opt to receive dental services that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at (877) 277-1112 or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document.

CARE FOLLOWING EMERGENCY SERVICES

After receiving any emergency or urgent care services, you will need to call your General Dentist for follow-up care.

REFERRALS TO SPECIALISTS-PATIENT FINANCIAL RESPONSIBILITY

Plan 1300 covers basic and routine preventive, restorative and major dental services available from participating primary care General Dentists. Plan 1300 also covers orthodontic services that are available from participating Orthodontists. This Plan does not cover any specialty services performed by non-contracting dental specialists, except for the aforementioned orthodontic services. Should your General Dentist need to refer you for consultation or specialized treatment, the Plan will assist with facilitating a referral to a specialist. The payment for services received from a non-contracting specialist except orthodontics will be the financial responsibility of the Plan Enrollee or Member.

TREATMENT AUTHORIZATION

The plan does not require prior authorization prior to obtaining dental services. Also, no prior authorization is required for emergency or urgent services (please refer to the “Definitions” section of this contract for a definition of emergency and urgent services). Additional questions can be directed to the Plan at (800) 277-1112.

OBTAINING A SECOND OPINION

Sometimes you may have questions about your condition or your dentist’s recommended treatment plan. You may want to get a second opinion. You may request a second opinion for any reason, including the following:
  • You question the reasonableness or necessity of a recommended procedure;
  • You have questions about a diagnosis or a treatment plan for a chronic condition or a condition that could cause loss of life, loss of limb, loss of bodily function, or substantial impairment.
  • Your provider’s advice is not clear, or it is complex and confusing,  Your provider is unable to diagnose the condition or the diagnosis is in doubt due to conflicting test results,
  • The treatment plan in progress has not improved your dental condition within an appropriate period of time;
  • You have attempted to follow the treatment plan or consulted with your initial provider regarding your concerns about the diagnosis or the treatment plan.
You should speak to your Dentist if you want a second opinion. After you or your Dentist has requested permission to obtain a second opinion, the Plan will authorize or deny your request in an expeditious manner. If your dental condition poses an imminent and serious threat to your health, including but not limited to, the potential loss of life, limb, or other major bodily function or if a delay would be detrimental to your ability to regain maximum function; your request for a second opinion will be processed within 72 hours after the Plan receives your request.
If your request to obtain a second opinion is authorized, you must receive services from a plan provider within your dental network. If there is no qualified provider in your network, the Plan will authorize a second opinion from a non-participating provider. You will be responsible for paying all copayments for the second opinion.
If your request to obtain a second opinion is denied and you would like to appeal our decision, please see the Plan Grievance and Appeals Process. This is a summary of the Plan policy regarding second opinions. To obtain a copy of our policy, please contact us at (800) 277-1112.

CONTINUITY OF CARE FOR NEW MEMBERS

Under some circumstances, the Plan will provide continuity of care for new Members who are receiving dental services from a non-participating dental provider when the Plan determines that continuing treatment with a non-participating provider is medically appropriate. If you are a new Member, you may request permission to continue receiving dental services from a nonparticipating provider if you were receiving this care before enrolling in the Plan and if you have one of the following conditions:
  • An acute dental condition. Completion of covered services shall be provided for the duration of the acute condition.
  • A serious chronic condition. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the Plan in consultation with you and the non-participating provider and consistent with good professional practice. Completion of covered services shall not exceed twelve (12) months from the time you enroll with the Plan.
  • Performance of a surgery or other procedure that your previous plan authorized as part of a documented course of treatment and that has been recommended and documented by the non-participating provider to occur within 180 days of the time you enroll with the Plan.
Please contact us at (800) 277-1112 to request continuing care or to obtain a copy of our Continuity of Care policy. Normally, eligibility to receive continuity of care is based on your medical condition. Eligibility is not based strictly upon the name of your condition. If your request is approved, you will be financially responsible only for applicable copayments under this plan.
We will request that the non-participating dentist agree to the same contractual terms and conditions that are imposed upon participating providers providing similar services, including payment terms. If the non-participating dentist does not accept the terms and conditions, the Plan is not required to continue that dentist’s services.
The Plan is not required to provide continuity of care as described in this section to a newly covered Member who was covered under an individual subscriber agreement and undergoing a treatment on the effective date of his or her plan coverage. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement.
The Plan will provide you a written explanation within thirty (30) days of our decision to approve or deny your request for continuity of care services. If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, please review the Plan Grievance and Appeals Process.
If you have further questions about continuity of care, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its tollfree telephone number, 1-888-HMO-2219; or at the TDD number for the hearing impaired, 1- 877-688-9891; or online at www.hmohelp.ca.gov.

CONTINUITY OF CARE FOR TERMINATION OF PROVIDER

If your primary care General Dentist or other dental care provider stops working with the Plan, we will let you know by mail 60 days before the contract termination date. The Plan will provide continuity of care for covered services rendered to you by a provider whose participation we have terminated if you were receiving this care from this provider prior to the termination and if you have one of the following conditions:
  • An acute dental condition. Completion of covered services shall be provided for the duration of the acute condition.
  • A serious chronic condition. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the Plan in consultation with you and the terminated provider and consistent with good professional practice. Completion of covered services shall not exceed twelve (12) months from the time you enroll with the Plan.
  • Performance of a surgery or other procedure that we have authorized as part of a documented course of treatment and that has been recommended and documented by the terminated provider to occur within 180 days of the provider’s contract termination date.
Continuity of care will not apply to providers who have been terminated due to medical disciplinary cause or reason, fraud, or other criminal activity. The terminated provider must agree in writing to provide services to you in accordance with the terms and conditions, including reimbursement rates, of his or her agreement with the Plan prior to termination. If the provider does not agree with these contractual terms and conditions and reimbursement rates, we are not required to continue the provider’s services beyond the contract termination date. Please contact the Plan to request continuing care or to obtain a copy of our continuity of care policy. Normally, eligibility to receive continuity of care is based on your dental condition. Eligibility is not based strictly upon the name of your condition. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement. If your request is approved, you will be financially responsible only for applicable copayments under this plan. The Plan will provide you a written explanation within thirty (30) days of our decision to approve or deny your request for continuity of care services. If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, see the Plan Grievance and Appeals Process on the following pages of this document.
If you have further questions about continuity of care, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its tollfree telephone number, 1-888-HMO-2219; or at the TDD number for the hearing impaired, 1- 877-688-9891; or online at www.hmohelp.ca.gov

CANCELLATION OF BENEFITS

If the contract between the Plan and the Individual or Family is terminated by the Plan for nonpayment of premiums when due, your coverage will be terminated on the last day of the month that premium was collected for and subject to compliance with notice requirements. Your coverage may be cancelled after not less than 15 days written notice for the following reasons:
  • Abusive or Disruptive Behavior – Repeated behavior that substantially impairs the Plan’s ability to furnish or arrange services for you and/or other enrollees or a provider’s ability to provide services to other patients.
  • Threatening the life of dental staff, providers or other plan members – Behavior that is abusive to the extent that it threatens the safety of employees, providers, members, and/or other patients.
  • Failure to Pay Charges other than Prepayment Fees – A failure to make a copayment or other charges to a provider or the Plan after being provided 31 days to pay such charges.
  • Failure to Reimburse the Plan for Payments Made in Error by the Plan on Your Behalf – A failure to reimburse the Plan for payments made in error on your behalf, after being provided 31 days to reimburse such payments.
  • Fraud or deception in the use of the services or facilities of the Plan or knowingly permitting such fraud or deception by another such other good cause as agreed upon between the Plan and a group or you.
  • Nonpayment If the Subscriber fails to make any past due payment within 15 days after monthly notice to the Subscriber of the amount due, Dedicated Dental may terminate the Individual Contract effective immediately upon written notice; ORIf the Subscriber and/or Member fails to pay any amount due to Dedicated Dental or plan provider within fifteen days after notice to the Subscriber and/or Member of the amount due. Dedicated Dental may terminate the rights of the Subscriber and/or Member and all dependents effective immediately upon written notice. These rights may only be reinstated by payment of the amounts due and by renewed application and re-enrollment. Services received after the effective date of termination will be charged to the Subscriber on a feefor- service basis.
  • Furnishing Incorrect or Incomplete Information: If the Subscriber and/or Member knowingly furnishes incorrect or incomplete information on the application, questionnaire, forms or statements submitted to Dedicated Dental incident to enrollment, the rights of the Subscriber and/or Member and all dependents may be terminated effective immediately upon written notice.
  • Misuse of Identification Card: If any Subscriber and/or Member permits the use of his or her Plan identification card by any other person, or uses another person’s card, the card may be retained by the Plan, and all rights of the Subscriber and/or Member who wrongfully permitted such use may be terminated effective upon written notice.
Under no circumstances will your coverage be terminated due to your health status or need for dental care. If you believe your enrollment has been terminated due to your health status or need for dental care, you may request a review of the termination by the California Department of Managed Health Care.

DISENROLLMENT

The 1300 Plan term is twelve months/one year. You may dis-enroll from the plan at the end of the term of the contract period which is twelve months/one year. For the monthly payment plan, (monthly payments made through the “Authorization Agreement for Checking Account Debit form,”) you may dis-enroll from the plan at the end of the term of the contract period which is twelve months/one year once the plan receives a 30 day written notice of cancellation from the Subscriber.RENEWAL PROVISIONS

You can renew your plan for an additional year by paying an annual reenrollment fee to Dedicated Dental Systems before your initial eligibility terminates. Dedicated Dental will send you a written notice about this at least thirty (30) days prior to the expiration of eligibility. Upon reenrollment you (and if applicable your eligible family members) will receive new identification cards. The same procedure will be used to reenroll for succeeding years. Other than payment of the required reenrollment fee, there is no condition or restrictions on your right to reenroll. If you want to dis-enroll after the annual period, please provide the Plan a 30 day written notice of your intent to terminate coverage

CANCELLATION OF SERVICES

You will have thirty (30) days after you receive your identification card(s) to cancel your eligibility and receive a full refund of your enrollment fee (but not the processing fee). However, no cancellation will be permitted if you or any eligible family member received services from a Network Dentist during this 30-day period (services include exam and x-rays). To receive your refund you must return to Dedicated Dental all identification cards that were given to you and your family members, along with a written request for the refund.

Other than as stated above, you cannot cancel any enrollment or reenrollment and receive any refund of your enrollment or reenrollment fee. However, you can terminate your eligibility after any one-year period by simply choosing not to reenroll.

Dedicated Dental cannot cancel your enrollment, or refuse to permit you to reenroll after any one-year period of eligibility ends, unless you or any of your eligible family members has engaged in fraud in using this plan. However, if you believe that Dedicated Dental has cancelled your enrollment or refused reenrollment because of your or any family member’s health status, you may contact the California Department of Managed Health Care at 1-888-HMO-2219 (for hearing or speech impaired persons at 1-877-688-9891) or contact the Department on-line at www.hmohelp.ca.gov.

PROCESSING AND ENROLLMENT FEES

Upon enrollment you will pay a one-time processing fee of $10.00 and your initial enrollment fee. Applicable enrollment and reenrollment fees are as follows:
You Only: $ 59.00
You and Your Spouse: $ 79.00
You and All of Your Eligible Family Members: $ 99.00

REINSTATEMENT

Receipt by the Plan of the proper prepaid or periodic payment after cancellation of the contract for non-payment shall reinstate the contract as though it had never been cancelled if such payment is received on or before the 20th day of the current month.

MEMBER RIGHTS AND RESPONSIBILITIES

As a Plan Member, you have the right to:
  • Be treated with respect and dignity.
  • Choose your General Dentist provider from our Provider Directory.
  • Get appointments within a reasonable amount of time.
  • Participate in candid discussions and decisions about your dental care needs, including appropriate or medically necessary treatment options for your condition(s), regardless of cost or regardless of whether the treatment is covered by the plan.
  • Have your records kept confidential. This means we will not share your dental care information without your written approval or unless it is permitted by law.
  • Voice your concerns about the Plan or about dental services you received, to the Plan.
  • Receive information about the Plan, our services, and our providers.
  • Make recommendations about your rights and responsibilities.
  • See your dental records.
  • Get services from providers outside of our network in an emergency.
  • Request an interpreter at no charge to you.
  • Use interpreters who are not your family Members or friends.
  • File a complaint if your linguistic needs are not met.
Your responsibilities are to:
  • Give your providers and the Plan correct information.
  • Understand your dental problems(s) and participate in developing treatment goals, as much as possible, with your provider.
  • Always present your Member Identification Card when getting services.
  • Ask questions about any dental condition and make certain that the explanations and instructions are understandable.
  • Make and keep dental appointments. You should inform your provider at least 24 hours in advance when an appointment must be cancelled.
  • Help the Plan maintain accurate and current medical records by providing timely information regarding changes in address, contact information, family status, and other health care coverage.
  • Notify the Plan as soon as possible if a provider bills you inappropriately or if you have a complaint.
  • Treat all the Plan personnel and providers respectfully and courteously.

CONFIDENTIALITY OF MEDICAL RECORDS

The Plan is committed to maintaining the confidentiality and security of all members’ medical information. The Plan may not disclose members’ medical information without the member’s authorization, unless required or permitted by law. Any disclosure of medical information beyond the provisions of the law is prohibited. The Plan has instituted procedures to implement this confidentiality policy. These procedures ensure that a member’s medical information is kept confidential.

THE PLAN’S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS ARE AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.

GRIEVANCE AND APPEALS PROCESS

Our commitment to you is to ensure not only quality of care, but also quality in the treatment process. This quality of treatment extends from the professional services provided by Plan providers to the courtesy extended to you by our telephone representatives. If you have questions about the services you receive from a Plan dentist, we recommend that you first discuss the matter with your dentist. If you continue to have a concern regarding any service you received, call the Plan Member Services at (800) 277-1112; TDD/TTY for the hearing impaired at (877) 688-9891 or the California Relay Service at (800) 735-2929. Grievance You may file a grievance with the Plan at any time. A copy of the Plan Grievance Policy and Procedure is available to you by calling the Member Service number in the above paragraph. To begin the grievance process, you can call, write, or fax the Plan at:
Dedicated Dental Systems, Inc.
9800 La Cienega Blvd., Suite 800
Inglewood, CA 90301
Phone: (800) 277-1112
Fax: (866) 647-0699
www.Dedicated-Dental.com

The Plan will acknowledge receipt of your grievance within five (5) days and will send you a decision letter within thirty (30) days. If your grievance involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function; you or your provider may request that the Plan expedite its grievance review. The Plan will evaluate your request for an expedited review and, if your grievance qualifies as an urgent grievance, we will process your appeal within three (3) days from receipt of your request.
You are not required to file a grievance with the Plan before asking the Department of Managed Health Care to review your case on an expedited review basis. If you decide to file a grievance with the Plan in which you ask for an expedited review, the Plan will immediately notify you in writing that:
  • You have the right to notify the Department of Managed Health Care about your grievance involving an imminent and serious threat to health, and
  • We will respond to you and the Department of Managed Health Care with a written statement on the pending status or disposition of the grievance no later than 72 hours from receipt of your request to expedite review of your grievance.

REVIEW BY THE DEPARTMENT OF MANAGED HEALTH CARE

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against the Plan, you should first telephone the Plan at (800) 277-1112 (TDD/TTY for the hearing impaired at (877) 688-9891. and use the Plan grievance process before contacting the department. Using this grievance procedure does not prohibit any legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the Plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial view of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency and urgent medical services. The Department of Managed Health Care has a toll-free telephone number, 1 (888) HMO-2219, to receive complaints regarding health plans. The hearing and speech impaired may use the department’s TDD line (1- 877-688-9891) number, to contact the department. The Department’s Internet website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.

The Plan grievance process and the DMHC's complaint review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

BINDING ARBITRATION

Sometimes disputes or disagreements may arise between you and the Plan regarding the construction, interpretation, performance or breach of this Evidence of Coverage, or regarding other matters relating to or arising out of your Plan Membership. Typically, such disputes are handled and resolved through the Plan Grievance Procedures process described above. However, in the event that a dispute is not resolved in that process, the Plan uses binding Arbitration as the final method for resolving all such disputes, whether stated in tort, contract or otherwise, and whether or not other parties such as Employer Groups, health care providers, or their agents or employees, are also involved. In addition, disputes with the Plan involving alleged professional liability or dental malpractice (that is, whether any dental services rendered were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) also must be submitted to binding arbitration.
As a condition of enrollment in the Plan, you agree to submit all disputes you may have with the Plan, except those described below, to final and binding arbitration. Likewise, the Plan agrees to arbitrate all such disputes. This mutual agreement to arbitrate disputes means that both you and the Plan are bound to use binding Arbitration as the final means of resolving disputes that may arise between you, and thereby both parties agree to forego any right they may have to a jury trial on such disputes. However, no remedies that otherwise would be available to either party in a court of law will be forfeited by virtue of this agreement to use and be bound by the Plan binding arbitration process, except that there is no jury trial in arbitration. This agreement to arbitrate shall be enforced even if a party to the arbitration is also involved in another action or proceeding with a third party arising out of the same matter.

The Plan binding Arbitration process is administered by the American Arbitration Association (AAA), and any disputes you may have with the Plan must be submitted to AAA for handling. Arbitration can be initiated by obtaining a Demand for Arbitration Form from the AAA and filing it with the nearest AAA office. If an AAA office cannot be located nearby, the demand should be filed with the Los Angeles office at the following address:

American Arbitration Association
3055 Wilshire Boulevard
7th Floor
Los Angeles, California 90010-1108

The arbitrator is required to follow applicable state or federal law. The arbitrator may interpret this Evidence of Coverage, but will not have any power to change, modify or refuse to enforce any of its terms, nor will the arbitrator have the authority to make any award that would not be available in a court of law. At the conclusion of the arbitration, the arbitrator will issue a written opinion and award setting forth findings of fact and conclusions of law, and that award will be binding on all parties.

The parties will share equally the AAA administrative fees and any arbitrator’s fee involved in the arbitration. Each party also will be responsible for their own attorneys’ fees. In cases of extreme hardship to a Member, AAA may, upon your request, allocate all or a portion of your share of the AAA administrative fees and any arbitrator’s fees to the Plan. An application and instructions for seeking such a hardship allocation may be obtained by contacting the AAA office. Even if the AAA denies such a request by a Member, however, the arbitrator may make such an allocation at the conclusion of the arbitration as part of the final award.

DUAL COVERAGE

Coverage and benefits under the Dedicated Dental Individual and Family Plan will always be secondary to a Group Plan.
Workers’ Compensation - Should any benefit or service rendered result from a Workers’ Compensation Injury Claim, the Member shall assign his/her right to reimbursement from other sources to the Plan or to the participating provider who rendered the service.

THIRD PARTY RECOVERY PROCESS AND MEMBER RESPONSIBILITIES

The Member agrees that, if benefits of this Agreement are provided to treat an injury or illness caused by the wrongful act or omission of another person or third party, provided that the Member is made whole for all other damages resulting from the wrongful act or omission before the Plan is entitled to reimbursement, Member shall:
  • Reimburse the Plan for the reasonable cost of services paid by the Plan to the extent permitted by California Civil Code section 3040 immediately upon collection of damages by him or her, whether by action or law, settlement or otherwise; and
  • Fully cooperate with the Plan effectuation of its lien rights for the reasonable value of services provided by the Plan to the extent permitted under California Civil Code section 3040.
The Plan lien may be filed with the person whose act caused the injuries, his or her agent or the court.The Plan is entitled to payment, reimbursement, and subrogation in third party recoveries and Member shall cooperate to fully and completely effectuate and protect the rights of the Plan including prompt notification of a case involving possible recovery from a third party.

NON-DUPLICATION OF BENEFITS WITH WORKERS’ COMPENSATION

Should any benefit or service rendered result from a Workers’ Compensation Injury Claim, the Member shall assign his/her right to reimbursement from other sources to the treating dentist who rendered the service. If, pursuant to any Workers’ Compensation or Employer’s Liability Law or other legislation of similar purpose or import, a third party is responsible for all or part of the cost of dental services provided by a contracted dentist, the Member will agree to provide treating dentist with a lien to the extent of the reasonable value of the services provided. The lien may be filed with the responsible third party, his or her agent, or the court.

REIMBURSEMENT PROVISIONS – IF YOU RECEIVE A BILL

If you receive a bill from your Dentist that you do not understand or think you owe, please contact the dental office directly for an explanation. If the issue is not resolved to your satisfaction, you may contact the Plan Member Services at (800) 277-1112 for assistance.

PUBLIC PARTICIPATION AND POLICY

The Plan permits Members to participate in its Public Policy Committee with responsibilities to assure the comfort, dignity and convenience of Members who rely on Participating Dentists to provide Covered Services. Call the Member Services at (800) 277-1112 if you would like more information.
NOTIFYING YOU OF CHANGES IN THE PLAN Throughout the year, we may send you updates about changes in the Plan. This can include updates for the Provider Directory, fee schedules, and Individual Contract. We will keep you informed and are available to answer any questions you may have. Call us toll-free (800) 277- 1112 if you have any questions about changes in the Plan.

ORGAN AND TISSUE DONATION

Donating organs and tissues provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak with your physician. Organ donation begins at the hospital when a patient is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities. The Department of Health and Human Services' Internet website (http://www.organdonor.gov) has additional information on donating your organs and tissues.

DEFINITIONS

Acute Condition A medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration.

Aesthetic Dentistry

Dental procedures which are performed purely for cosmetic purposes.

Appointment Waiting Time

The Time from the initial request for dental services by an enrollee to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its contracted dentists.

Appropriately Qualified Dental Care Professional

A licensed dental care provider who is acting within his or her scope of practice and who possesses a clinical background including training and expertise, related to a particular illness, disease, condition or conditions.

Knox Keene Act and Regulations

Knox-Keene Health Care Service Plan Act of 1975, as amended, as set forth at Chapter 2.2. of Division 2 of the California Health and Safety Code (beginning with Section 1340), and its implementing regulations, as set forth at Subchapter 5.5 of Chapter 3 of Title 28 of the California Code of Regulations (beginning with Section 1300.41).

Benefits and Covered Services

The dental care services available under the Individual Contract in which a Member is enrolled.

Benefit Year

The twelve (12) month period commencing the first day of the month of initial date of enrollment of each year at 12:01 AM.

Child

All natural, adopted, foster, and stepchildren.

Individual Contract/Combined Evidence of Coverage/Disclosure Form

This document which is issued to the Subscriber and/or Member setting forth the benefits and coverage to which the Subscriber and/or Member is entitled, as well as the terms of the Individual Contract, to afford the public, Subscribers and/or Members with a full and fair disclosure of the provisions of the Plan in readily understood language and in a clearly organized manner.

Copayment

The fee charged to a Subscriber and/or Member which is approved by the California State Department of Managed Health Care, provided for and disclosed in the Individual Contract.
Dental Facilities Those centers selected by the Plan to provide dental services for Subscribers and/or Members.

Dependent:

  1. The Subscriber’s lawful spouse or domestic partner;
  2. An unmarried dependent child of the Subscriber, up to the child’s 26th birthday;
  3. An unmarried child of the Subscriber, up to the child’s 26th birthday who is a full-time student and is wholly dependent on the Subscriber for support;
  4. Any otherwise eligible child of the subscriber, regardless of age, who is a) incapable of selfsustaining employment by reason of a physically or mentally disabling injury, illness, or condition (proof of disability is required) and b) chiefly dependent upon the subscriber for support and maintenance.

Effective Date of Coverage

The date upon which the Subscriber and/or Member is entitled to receive the benefits and coverage which are available under this Individual Contract.

Emergency or Urgent Care

Services required for alleviation of severe pain or bleeding and/or immediate diagnosis and treatment if unforeseen conditions which, if not immediately diagnosed and treated may lead to disability, dysfunction, or death.

Emergency Dental Condition

A dental condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate dental attention could reasonably be expected to result in any of the following:
  1. Placing the patient’s health in serious jeopardy.
  2. Serious impairment to bodily functions.
  3. Serious dysfunction of any bodily organ or part.

Exclusion

Any dental treatment or service not covered under this Plan..

Family Member

Any individual of an Applicant or Member’s immediate family who meets all applicable eligibility requirements as defined by the Plan.

Grievance

A written or oral expression of dissatisfaction regarding the plan and/or a provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by a Member or the Member's representative

Limitation

Any provision other than an exclusion which restricts coverage under the Individual Contract.

Member

Any Subscriber or dependent, as defined above, enrolled under the Individual Contract and entitled to the benefits and coverage available under the Individual Contract in return for the payment required to be made to the Plan under such Individual Contract.

Member Identification Card

The identification card provided to Members by the Plan that includes the Member number, their assigned General Dentist information, and important telephone numbers.

Medically Necessary

Those dental treatments or supplies which are (a) furnished in accordance with professionally recognized standards of practice; (b) determined by the treating physician to be consistent with the dental condition; and (c) furnished at the most appropriate type, supply and level of service which considers the potential risks, benefits and alternatives.

Non-Covered Benefit

Any dental procedure not a covered benefit listed as a benefit in this Individual Contract’s Schedule of Benefits.

Non-Participating Provider

A dentist that has no contract to provide services for the Plan.

Out-of-area services

Emergency care or urgent care services provided outside of the dental plan’s service area that could not be delayed until the member returned to the service area.

Participating Dentist

Those dentists who have agreed to provide dental services for Subscribers and /or Members of the Plan.

Plan

Dedicated Dental Systems, Inc. (DDSI).

Provider

A licensed dentist who provides dental services. A provider may be a participating dentist if he or she has an agreement with the Plan to provide covered services to members..

Plan Provider

Providers of dental services licensed by the State to deliver or furnish these services, which have contracts with the Plan to render services to Subscribers and/or Members in accordance with provisions of this Individual Contract. The names, locations, hours of services and other information regarding Plan providers and facilities may be obtained by contacting the Plan at (800) 277-1112.

Prepayment Fee

Amount payable monthly on a prepayment basis by the Subscriber and/or Member to obtain benefits and coverage under the Individual Contract.

Preventive Care

Dental services provided for prevention and early detection of disease.

Primary Care General Dentist

Plan provider chosen by the Subscriber and/or Member and designated by the Plan to be responsible for the general dental care of the Subscriber and/or Member and their dependents, and who is receiving the consideration provided in the Dental Provider Agreement for the primary dental care of such Subscriber and/or Member.

Provider Directory

The directory of all the providers contracted with the Plan to provide services to its Members.

Serious Chronic Condition

A medical condition due to a disease, illness or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration.

Service Area

The geographic area that the Plan is licensed by the California Department of Managed Health Care to operate.

Subscriber

The person who is responsible for payment to the Plan or whose status, except family dependency, is the basis for eligibility for membership in the Plan.

Terminated Provider

A dentist that formerly delivered services under contract that is no longer associated with the Plan.

Usual Fee

The customary fee that a dentist most frequently charges for a specific dental procedure or service.

Limitations:

  1. Plan 1300 covers basic and routine preventive, restorative and major dental services available from participating General Dentists. Plan 1300 also covers orthodontic services that are available from participating Orthodontists. This Plan does not cover any services received from specialists with the exception of orthodontic services. Should your General Dentist need to refer you for consultation or specialized treatment, the Plan will assist with facilitating a referral to a specialist. The payment for services received from a non-contracting specialist except orthodontics will be the financial responsibility of the Plan Enrollee or Member.
  2. Any procedure started before the effective coverage date may be covered, subject to the limitations described within “Continuity of Care.”
  3. Prophylaxis, (adult and child) is limited to once every six months.
  4. Fluoride treatments are limited to once every six months.
  5. Replacement of Crowns, Bridge Units and Dentures is limited to once every five years.
  6. Full and partial denture relines are limited to once every two years.
  7. Full and partial denture adjustments are limited to three adjustments within six months of delivery.
  8. Orthodontic benefits cover 24 months of active banding/orthodontic treatment and 12 months of retention.
  9. Services performed by a non-participating provider are not covered.

Exclusions:

  1. Services that are not appropriate or necessary for the diagnosis, care or treatment of the condition involved, based on professionally recognized standards of dental practice.
  2. Any cosmetic services used (or used as a substitute) primarily to improve or enhance appearance, i.e., dental procedures which are performed purely for cosmetic purposes. Veneers or bonding for stained teeth would be considered cosmetic.
  3. Medical treatment needed to correct a congenital condition or defect before necessary dental services can be performed.
  4. General anesthesia, IV sedation, or an Anesthesiologist or Nurse Anesthetist.
  5. Recontouring of natural teeth.
  6. Crown-lengthening.
  7. Treatment solely for abrasion or erosion, unless the service is found to be appropriate and necessary based upon professionally recognized standards of practice.
  8. Precision attachments.
  9. Replacement for natural teeth that may have been lost prior to coverage under this plan.
  10. Extractions without clinical pathology or for orthodontic purposes only.
  11. Procedures, restorations, or appliances intended to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders.
  12. Treatment of malignancies, cysts or neoplasms.
  13. Any dental services or procedures not specifically listed as a covered benefit under this plan.
  14. Dental services considered to be unnecessary or experimental.
  15. Dental procedures initiated prior to a member’s eligibility under this Plan or started after termination of coverage under this Plan.
  16. Dental services or appliances that are determined to not be reasonable and/or necessary for maintaining or improving the Member’s dental health as determined by the treating dentist.

Orthodontic Benefit Limitations and Exclusions

Listed below are those services limited or expenses NOT covered under the plan. If rendered, the member is responsible for payment of the dentist's fee.
  1. Orthodontic benefits are available only at a participating orthodontic office.
  2. If the member relocates to an area and is unable to receive treatment with the original participating orthodontist, coverage under this program ceases and it becomes the obligation of the member to pay the usual and customary fee of the orthodontist where treatment is completed.
  3. Covered treatment cannot be transferred by the member from on participating orthodontist to another participating orthodontist.
  4. No benefit will be paid for an orthodontic treatment program that began before the member enrolled in the orthodontic plan.
  5. If the member becomes ineligible during the course of treatment, coverage under this program ceases and it becomes the obligation of the member to pay the usual and customary fees incurred for the entire remaining balance of treatment.
  6. Orthognathic surgery cases and cases involving cleft palate, micrognathia, macroglossia, hormonal imbalances, temporomandibular joint disorders (T.M.J.), or myofunctional therapy.
  7. Re-treatment of orthodontic cases, changes in treatment necessitated by an accident of any kind, and treatment due to neglect or non-cooperation are excluded.
  8. The following are not included in the orthodontic benefits and the orthodontist's usual and customary charges apply: 1: Lingual or clear brackets; 2: Replacement of lost or broken appliances, bands, brackets or orthodontic retainers.

Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

A Deductibles None
B Lifetime maximums. None
C Professional services. Dental services only
D Outpatient services. Not covered
E Hospitalization services. Not covered
F Emergency health coverage.For dental services only
G Ambulance services. Not covered
H Prescription drug coverage. Not covered
I Durable medical equipment. Not covered
J Mental health services. Not covered
K Chemical dependency services. Not covered
L Home health services. Not covered
M OtherNot Applicable

IF YOU COMPLETE AND SUBMIT THE ENROLLMENT FORM, YOU AGREE TO BE BOUND BY ALL THE TERMS AND CONDITIONS IN THIS DESCRIPTION.