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

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made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the forxn of services. Right of Recovery If Delta Dental pays more than it should have paid under this COB provision, it may recover the excess from the people it has paid or for whom it has paid. Payrnent includes the reasonable cash value of any benefits provided in the forxn of services. This right of recovery is limited to two years after the date of the original claim payment, unless Delta Dental has reasonable belief that fraud or intentional misconduct occurred. IX. Disputed Claims Procedure When Delta Dental is the Secondary Plan, it will pay for Covered Services based on the amount left after the Primary Plan has paid. It will not pay more than that amount, and it will not pay more than it would have paid as the Primary Plan. Delta Dental may, however, pay less than it would have paid as the Primary Plan. When Delta Dental's payments are reduced as described above, each payxnent is reduced in proportion. The payments are then charged against any applicable benefit limit. Right to Receive and Release Needed Information Delta Dental needs certain facts to apply these COB rules, and it has the right to decide which facts it needs. It may get needed facts from, or give them to, any other organization or person. Delta Dental need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must give Delta Dental any facts it needs to pay the claim. Facility of Payment A payment made under another plan may include an amount that should have been paid under this Plan. If it does, Delta Dental may pay that amount to the organization that made the payment. That amount will then be treated as though it were a benefit paid under this Plan, and Delta Dental will not have to pay that amount again. The term "payment Delta Dental will notify you or your authorized representative if you receive an adverse benefit determination after your claim is filed. An adverse benefit determination is any denial, reduction, or termination of the benefit for which you filed a claim, or a failure to provide or to make payxnent (in whole or in part) of the benefit you sought. This includes any such determination based on eligibility, application of any utilization review criteria, or a determination that the item or service for which benefits are otherwise provided was experimental or investigational or was not medically necessary or appropriate. If Delta Dental informs you that the Plan will pay the benefit you sought but will not pay the total amount of medical expenses incurred, and you must make a Copayment to satisfy the balance, you may also treat that as an adverse benefit deternunation. ff you receive notice of an adverse benefit deternunation, and if you think that Delta Dental incorrectly denied a11 or part of your claim, you can take the following steps: First, you or your Dentist should contact Delta Dental's Customer Service department at their toll-free number, (800) 662-8856, and ask them to check the claim to make sure it was processed correctly. You may also mail your inquiry to the Customer Service department at P.O. Box 9089, Farmington Hills, Michigan, 48333-9089. When writing, please enclose a copy of your Explanation of Benefits and describe the problem. Be sure to include your name, your telephone number, the date, and any information you Form No. 1752-NC 14 NCPPOpIus-A 01 /2012 How Delta Dental Pays as Secondary Plan