2012-038 Human Resources - Delta Dental Claims & Administrative fees

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available annual or lifetime Maximum Payments, any coordination of benefits, the status of your Plan and your Dentist, your Plan's limitations and any other Plan provisions. A request for a Predeternunation is not a claim for Benefits or a preauthorization, precertification or other reservation of future Benefits. Processinq Policies Delta Dental's policies and guidelines used for Predetermination and payment of claims. The Processing Policies may be amended from time to time. Submitted Amount The amount a Dentist bills to Delta Dental for a specific treatrnent or service. Subscriber You, when your employer or organization notifies Delta Dental that you aze eligible to receive dental benefits under your employer's or organization's Plan. Summarv of Dental Plan Benefits A description of the specific provisions of your group dental Plan. The Summary of Dental Plan Benefits is, and should be read as, a part of this Certificate, and supersedes any contrary provision of this Certificate. III. Selecting a Dentist You may choose any Dentist. Your out-of-pocket costs are likely to be less if you go to a Delta Dental PPO Dentist. PPO Dentists agree to accept payment according to the PPO Denrist Schedule, and, in most cases, this results in a reduction of their fees. Delta Dental may also pay a higher percentage for Covered Services if you go to a PPO Dentist. If the Dentist you select is not a PPO Dentist, you will still be covered. Your coverage levels may be slightly lower, but you can still save money. In this case, there aze two options: • If you go to a Non-PPO Dentist who participates in Delta Dental Premier, the fee reduction is not the same as with the PPO Dentists. However, Premier Dentists agree to accept Delta Dental's Maximum Approved Fee as payment in full for Covered Services. • If you choose a Dentist who does not participate in either program, you will be responsible for any difference between Delta Dental's allowed fee and the Dentist's Submitted Amount, in addition to any Copayments and/or Deductibles. IV. Accessing Your Benefits To use your Plan, follow these steps: 1. Please read this Certificate and the Summary of Dental Plan Benefits carefully so you are familiar with the benefits, payment mechanisms, and provisions of your Plan. 2. Make an appointment with your Dentist and tell him or her that you have dental benefits coverage with Delta Dental. If your Dentist is not familiar with your Plan or has questions about the Plan, have him or her contact Delta Dental by (a) writing Delta Dental, Attention: Customer Service, P.O. Box 9089, Farnrington Hills, Michigan, 48333- 9089, or (b) calling the toll-free number, (800) 662-8856. 3. After you receive your dental treahnent, you or the dental office staff will file a claim form, completing the information portion with: a. The Subscriber's full name and address; b. The Subscriber's Member ID number; c. The name and date of birth of the person receiving dental care; d. The group's name and number. Form No. 1752-NC 5 NCPPOpIus-A Ot/2012 To verify that a Dentist is a Participating Dentist, you can use Delta Dental's online Dentist Directory at www.deltadentalnc.com or ca11(800) 662-8856.