Welcome to Delta Dental of Massachusetts!

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1 Welcome to Delta Dental of Massachusetts! An Independent Licensee of the Delta Dental Plans Association. Registered marks of the Delta Dental Plans Association DSM.

2 Table of Contents INTRODUCTION... 1 Contact Us... 2 SELECTING YOUR DENTIST... 2 Free Choice of Dentist... 2 Referrals to Specialists... 2 Locating a Delta Dental Participating Dentist... 3 PLAN INFORMATION... 3 Benefit Summary...4 Deductible... 5 Coinsurance... 5 Maximum Benefit... 5 Limitations and Exclusions... 5 HOW CLAIMS ARE PAID... 7 Payment of Performance...8 Orthodontic Payments... 9 How to Submit a Claim... 9 Payment Guidelines... 9 Optional Treatment and Non-Covered Services Pre-Treatment Estimates Other Health Insurance ELIGIBILITY AND ENROLLMENT Changes in Eligibility Status Loss of Eligibility COMPLAINTS, GRIEVANCES AND APPEALS Appeals ADDITIONAL IMPORTANT INFORMATION Proof of Claim Physical Access DEFINITIONS AND TERMS... 13

3 INTRODUCTION Delta Dental of Massachusetts is pleased to welcome you to the group dental plan for the Roman Catholic Archdiocese of Boston Health Benefit Trust. Our goal is to provide you with the highest quality dental care and help you maintain good oral health. We encourage you not to wait until you have a problem to see the dentist, but to see your dentist on a regular basis. These materials offer terms and conditions of your dental plan coverage. We offer this information to help you understand how the plan works and how to obtain dental care. Keep in mind that YOU and YOUR mean the individuals who are covered. WE, US and OUR always refer to Delta Dental. The benefit explanations contained in this booklet are subject to all provisions of the Group Dental Service Contract on file with your employer, trust fund, or other entity ( Plan Administrator ) and do not modify the terms and conditions of that contract in any way, nor shall you accrue any rights because of any statement in or omission from this booklet. For detailed information on your group s plan, riders, terms and conditions, or limitations and exclusions, please see the Subscriber Certificate, which can be obtained through your plan administrator. Member Rights and Responsibilities You have the right to: Be provided with appropriate information about Delta Dental and its benefits, providers, and policies. Be informed of your diagnosis, the proposed treatment, and prognosis by your dentist. Give informed consent before beginning any dental treatment and be made aware of the consequences of refusing treatment. Obtain a copy of your dental record, in accordance with the law. Be treated with respect, and have your dignity and need for privacy recognized. You have the responsibility to: Ask questions in order to understand your dental condition and treatment, and follow instructions for recommended treatment given by oral health providers. Provide dentists with the information necessary to care for you. Be familiar with Delta Dental benefits, policies, and procedures by reading Delta Dental s printed and web-based materials. Disclaimer: The information provided in this document is a summary and is intended for illustration purposes only, is not guaranteed to be error free or complete, and does not constitute an offer or a contract. No person should act, fail to act, or rely on and Delta Dental assumes no liability for use or interpretation of the information contained in this brochure. Please see your group contract and subscriber s certificate for the applicable plan for complete details of the plan. Should any discrepancy arise, any such contract(s) and certificate(s) supersede this illustration. 1 P a g e

4 Contact Us If you have questions that are not answered here, please visit our website,, or call our Customer Service Center, or toll-free at If you prefer to write Delta Dental with your question(s), you can do so via to or by mail: 465 Medford Street, Boston MA Customer service representatives, available Monday through Thursday from 8:30 a.m. 8:00 p.m. and Fridays from 8:30 a.m. to 4:30 p.m. EST, can answer questions you may have about obtaining dental care, help you locate a participating dentist, explain benefits, check the status of a claim, and assist you in filing a claim. You can also access automated information about eligibility, benefits or claims status by dialing SELECTING YOUR DENTIST Free Choice of Dentist Delta Dental recognizes that many factors affect your choice of a dentist, and we support your right to choose one that best fits your needs. You may see any licensed dentist for your covered treatment. Delta Dental organizes oral health providers into networks. Dentists who participate in a network agree to the terms and conditions of our network agreements. Your dental insurance plan, called Delta Dental PPO Plus Premier, is specific to the Delta Dental PPO network and the Delta Dental Premier network. An estimated 96% of dentists in Massachusetts belong to one or both of these networks. Dentists who agree to participate in our Delta Dental PPO network accept greater discounts on their fees, so you enjoy the greatest savings when you choose a PPO dentist. You are also welcome to see a dentist who does not participate in either of these networks. In addition, you may choose your own specialist, and you and your family members can see different dentists. Dentist Selection Tip To take full advantage of your benefits, we suggest you verify your dentist s participation status within a Delta Dental network before each appointment. Review the section titled How Claims Are Paid for an explanation of Delta Dental payment procedures. Knowing how out-ofpocket costs vary based on what network your dentist is in may influence your dentist selection. Referrals to Specialists Your dentist may refer you to another dentist for a consultation or specialized treatment, or you may elect to see a specialist on your own. If you are referred to a specialist, it is your responsibility to ensure the dentist you are referred to is a participating dentist. You can do this by simply asking the specialist when you make your appointment. Visiting a dentist who has agreed to participate in the Delta Dental network can save you money, time, and the hassle of paperwork. Remember, if the dentist is not a participating dentist, you may be required to pay all of the treatment cost at the time of 2 P a g e

5 service and submit a claim to Delta Dental for reimbursement. Locating a Delta Dental Participating Dentist There are two ways you can locate a participating dentist near you: 1. Call Delta Dental at and one of our customer service representatives will assist you. If you call outside of normal business hours, you can get help finding a dentist on our automatic telephone line. 2. You may access information about the plan through our website at /find-a-dentist. Our site includes a dentist search function, allowing you to locate Delta Dental participating dentists by location, specialty and network type. Delta Dental of Massachusetts PPO and Premier insurance products are offered by Dental Service of Massachusetts, Inc., an Independent Licensee of the Delta Dental Plans Association. Registered marks of the Delta Dental Plans Association DSM. PLAN INFORMATION Benefit Summary The services provided through the plan include the benefits described in the Benefit Summary Charts on the following page. Items presented in the Limitations and Exclusions section are NOT benefits that are part of your plan. The plan covers several categories of benefits when a licensed dentist provides the services and when they are within the standards of generally accepted dental practice. To help you understand the types of procedures that are included in each category of service, examples and descriptions are provided in the benefit plan summary. Your share may be higher than the percentages listed in the charts, depending on the applicability of deductibles, maximums, the difference between the Non-participating Dentist s fee and the Nonparticipating Dentist Maximum Plan Allowance or charges for non-covered services. 3 P a g e

6 Coverage Summary for Archdiocese of Boston Group # Deductible: $50 per individual / $150 per family. Deductible waived for Diagnostic and Preventive categories and fillings. Calendar Year Maximum: $1,500 per person. Category / Procedure Qualifications Delta Dental PPO Orthodontics: Covered at 50% of Maximum Plan Allowance charges to any age. $1,000 separate LIFETIME maximum. Dependent Eligibility: A dependent child is covered up to the last day of the month of his/her 19 th birthday; or until the last day of the month of his/her 23 rd birthday if attending an accredited educational institution as a full time student. Effective 10/01/2015: Eligible dependents are covered up to age 26 4 P a g e Co-insurance 4 P a g e Delta Dental Premier and Non- Participating Diagnostic 100% 100% Comprehensive Evaluation Once every 60 months. Periodic Oral Exam Two times in a calendar year. Full Mouth X- rays Once every 60 months. Bitewing X-rays Two times in a calendar year. Single Tooth X-rays As needed. Preventive 100% 100% Teeth Cleaning Two times in a calendar year. Fluoride Treatments Two times in a calendar year for members under age 19. Space Maintainers Required due to the premature loss of teeth. For members under age 19 and not for the replacement of primary or permanent anterior teeth. Sealants Unrestored permanent molars, every 4 years per tooth for members through age 15. Sealants are also covered for members aged 16 up to age 19 for those who had a recent cavity and are at risk for decay. Chlorhexidine Mouthrinse This is a covered benefit only when administered and dispensed in the dentist's office following scaling and root planing. Fluoride Toothpaste This is a covered benefit only when administered and dispensed in the dentist's office following periodontal surgery. Restorative 100% 100% Silver Fillings Once every 24 months per surface per tooth. White Fillings (Front Teeth) Once every 24 months per surface per tooth. White Fillings (Back Teeth) Covered only for single surfaces. Once every 24 months per surface, per tooth, multi-surfaces will be processed as a silver filling and the patient is responsible up to the submitted charge. Temporary Fillings Once per tooth. Stainless Steel Crowns Once every 24 months per primary tooth, after a pulpotamy. Oral Surgery 80% 80% Simple Extractions Once per tooth. Surgical Extractions Once per tooth. Periodontics 80% 80% Periodontal Surgery One surgical procedure per quadrant in 36 months. Scaling and Root Planing Once in 24 months, per quadrant. Periodontal Cleaning Four times in a calendar year following active periodontal treatment. Not to be combined with 100% 100% preventive cleanings. Endodontics 80% 80% Root Canal Treatment Once per tooth. Vital Pulpotomy Limited to deciduous teeth. Prosthetic Maintenance 80% 80% Bridge or Denture Repair Once within 12 months, same repair. Rebase or Reline of Dentures Once within 36 months. Recement of Crowns & Onlays Once per tooth. Emergency Dental Care 80% 80% Minor treatment for Pain Relief Three occurrences in 12 months. General Anesthesia General Anesthesia and IV sedation are allowed with covered surgical impacted teeth only. Prosthodontics 50% 50% Dentures Once within 60 months. Fixed Bridges and Crowns When part of a bridge. Once within 84 months. Implants Once per 60 months per Implant. Major Restorative 50% 50% Crowns When teeth cannot be restored with regular fillings. Once within 60 months per tooth.

7 Deductible Most dental plans have a dollar deductible. A deductible is an amount you must spend before certain portions of your dental care will be covered by the plan. Your deductible is $50 per person covered by the plan. Your deductible is waived for preventive and diagnostic services, along with periodontal cleanings and fillings. (This means we will cover these services regardless of whether you have met your deductible obligation.) Each enrolled family member must pay the individual deductible amount each calendar year to satisfy the plan deductible. You pay this directly to your dentist for completed services. Coinsurance Your dental plan will pay a percentage of the applicable allowed amount for each covered service, subject to certain limitations. On the benefit summary, this is called your coinsurance. It is sometimes referred to as your copayment. You pay this even after a deductible has been met. Coinsurance is a fixed percentage you pay for a service. Copayment is a fixed dollar figure you pay for a service. With Delta Dental of Massachusetts, you generally pay a coinsurance amount for procedures and services that covered at less than 100%. The applicable allowed amount we pay varies based on the network your dentist is in. Dentists in the Delta Dental PPO network generally agree to applicable allowed amounts that are lower than dentists in the Delta Dental Premier network. It is to your advantage to select PPO dentists because they have agreed to accept the PPO allowed amount as payment, which typically results in lower coinsurance charged to you. Please read the sections titled Selecting Your Dentist and How Claims Are Paid for more information. Maximum Benefit Most dental programs have an annual maximum benefit. This is the maximum dollar amount a dental plan will pay in a given year toward the cost of dental care. Your plan may also have a lifetime orthodontic benefit limit. The enrollee is responsible for paying costs above the maximum benefit. The Benefit Summary Charts show the maximum benefit amount that applies, depending on the participation status of the dentist providing the services. This is the maximum benefit amount that Delta Dental will pay for covered services per enrollee in a calendar year. Your plan has a $1,500 Calendar year maximum benefit, per person. There is a separate orthodontic LIFETIME maximum of $1,000 per person. Rollover Maximum Benefit The rollover maximum feature allows you to roll over a portion of your unused benefit dollars into subsequent years. If you have had at least one cleaning or checkup within the calendar year, and your total plan year claims do not exceed $700, you can roll over $500 towards the next year s annual maximum. The maximum accumulated rollover total is capped at $1,250. Limitations and Exclusions Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical program includes limitations and exclusions, meaning the program does not cover every aspect of dental care. This can relate to the type of procedures or the number of visits. Surgical services No benefits are provided for services when the covered individual s condition requires that he or she be admitted as an inpatient in a hospital or surgical day care center. However, we will consider review of the following in-hospital surgical procedures for coverage if they are not benefits under your medical carrier s contract: 5 P a g e

8 Necessary and appropriate services We provided benefits only for necessary and appropriate services. We will not provide benefits for a dental service that is not covered under the terms of your plan contract. In addition, we will not provide benefits for a covered dental service that is not necessary and appropriate to diagnose or to treat your dental condition as determined by Delta Dental. To be necessary and appropriate, a service must be consistent with the prevention of oral disease or with the diagnosis and treatment on (1) those teeth that are decayed or fractured or (2) those teeth where supporting periodontium is weakened by disease in accordance with standards of good dental practice not solely for your convenience or the convenience of your dentist. Delta Dental determines what is necessary and appropriate under the terms of the contract. That decision is made by Delta Dental based on a review of dental records describing your condition and treatment. We may decide a service is not necessary and appropriate under the terms of the contract even if your dentist has furnished, prescribed, ordered, recommended or approved the service. Blanket exclusions We do not provide benefits for: A service or procedure that is not generally accepted as determined by Delta Dental. A service or procedure that is not described as a benefit in your plan contract. Services that are rendered due to the requirements of a third party, such as an employer or school. Travel time and related expenses. An illness or injury that we determine arose out of and in the course of your employment. A service for which you are not required to pay, or for which you would not be required to pay if you did not have your plan contract. An illness, injury or dental condition for which benefits in one form or another are available, in whole or in part, through a government program or would have been available if you did not have your plan contract. A government program includes a local, state or national law or regulation that provides or pays for dental services. It does not include Medicaid or Medicare. We will not provide benefits if you could have received government benefits by applying for them within the appropriate agency s time limitation. A method of treatment more costly than is customarily provided. Benefits will be based on the least costly method of treatment. A separate fee for services rendered by interns, residents, fellows or dentists who are salaried employees of a hospital or other facility. Appointments with your dentist that you fail to keep. Dietary advice and instructions in dental hygiene including proper methods of tooth brushing, the use of dental floss, plaque control programs and caries susceptibility tests. A service rendered by someone other than a licensed dentist or a hygienist who is employed by a licensed dentist. Consultations. A service to treat disorders of the joints of the jaw (temporomandibular joints). A service, supply or procedure to increase the height of teeth (increase vertical dimension) or restore occlusion. Restorations for reasons other than decay or fracture, such as erosion, abrasion, or attrition. Services that are meant primarily to change or to improve your appearance. Occlusal guards for the treatment of disorders of the joints of the jaw or for bruxism (grinding) 6 P a g e

9 Replacement of dentures, bridges,space maintainers or periodontic appliances due to theft or loss. Services, supplies or appliances to stabilize teeth when required due to periodontal disease such as periodontal splinting. Lab exams. Photographs. Laminate veneers. Duplicate dentures and bridges. Temporary complete dentures and temporary fixed bridges or crowns. Stainless steel crowns on permanent teeth. Cast restorations, copings and attachments for installing overdentures. Services related to congenital anomalies. However, this exclusion does not apply to orthodontic services that may be covered by your group s orthodontic rider. Tooth desensitization. Occlusal adjustment. HOW CLAIMS ARE PAID Payment by Delta Dental for any single procedure that is a covered service will be made upon completion of the procedure. If you use an in-network dentist, the dentist will submit the claim form to Delta Dental. The dentist will charge you for your coinsurance amount directly. If you use an out-of-network dentist for the procedure, you will be billed by the dentist directly. You must submit a claim form to us and we will reimburse you for some or all of the claim amount pursuant to the terms and conditions of your plan. Your payment for care is applied to your calendar year deductible and maximum benefit based on the date of service, or the date the procedure was completed. After you have satisfied your deductible requirement, Delta Dental will provide payment for covered services at the percentage indicated in the Benefit Summary Chart, up to a maximum for each enrollee in a calendar year. 7 P a g e

10 Delta Dental PPO network dentist Payment for covered services performed by a PPO dentist is calculated based on the PPO maximum allowable charges that PPO dentists have agreed to accept as the full charge for covered services. Delta Dental calculates its share of the maximum plan allowance, or the dentist s submitted fee, whichever is less, using the applicable percentage from the Benefit Summary Chart and sends it directly to the PPO dentist who submitted the claim. Delta Dental advises you of any charges not payable by Delta Dental for which you are responsible. These charges are generally your share of the maximum plan allowance or submitted fee (coinsurance), the deductible, charges where the maximum benefit has been exceeded, and/or charges for non-covered services. Payment for Services Delta Dental Premier network dentist A Delta Dental Premier dentist is one who agrees to the Delta Dental Premier fee agreement. This agreement details the maximum allowance charge for oral health services. These are generally lower than retail, but not as low as those agreed to by the Delta Dental PPO dentists. Payment for covered services performed by a Premier dentist is calculated based on the Premier allowed amount, which is the lesser of the dentist s submitted fee or the Premier maximum plan allowance. The portion of the Premier allowed amount payable by Delta Dental is limited to the applicable percentage shown in the Benefit Summary Chart. Delta Dental s Payment is sent directly to the Premier dentist who submitted the claim. Delta Dental advises you of any charges not payable by Delta Dental for which you are responsible. These charges are generally your share of the Premier allowed amount. Out-of-network dentist Payment for services performed by an out-of-network dentist is also calculated by Delta Dental based on the Non-participating Dentist Allowed Amount, which is the lesser of the dentist s submitted fee or the Nonparticipating Dentist Maximum Plan Allowance. The portion of the Nonparticipating Dentist Allowed Amount payable by Delta Dental is limited to the applicable percentage shown in the Benefit Summary Chart. However, when dental services are received from an out-ofnetwork dentist, our payment is sent directly to the primary enrollee. You are responsible for payment of the Non-participating Dentist s total fee. Nonparticipating Dentists will bill you for their normal charges, which may be higher than the Nonparticipating Dentist Allowed Amount for the service. You may be required to pay the dentist yourself and then submit a claim to Delta Dental for reimbursement. Since the Delta Dental Payment for services you receive may be less than the Non-participating Dentist s actual charges, your out-of-pocket cost may be significantly higher. 8 P a g e

11 Here is an example of what you could save on a porcelain crown, which is covered by your plan at 50%. Delta Dental PPO Network Fee charged by dentist $1,288 Delta Dental PPO network allowed amount $ 928 Delta Dental portion (50%) $ 464 Your portion (50%) $ 464 Because you used a Delta Dental PPO network dentist, you pay $244 less than you would if you went to an out-of-network dentist. Delta Dental Premier Network Fee charged by dentist $1,288 Delta Dental Premier network allowed amount $1,094 Delta Dental portion (50%) $ 547 Your portion (50%) $ 547 Because you used a Delta Dental Premier network dentist, you pay $161 less than you would if you went to an out-of-network dentist. Out-of-network dentist Fee charged by dentist $1,288 Delta Dental out-ofnetwork allowed amount $1,160 Delta Dental portion (50%) $ 580 Your portion $ 708 Your payment amount is made up of the 50% coinsurance amount plus the difference between the dentist s submitted charge and the maximum allowable charge. *The information provided in this example is intended for illustration purposes only. Please see your contract with Delta Dental, as well as reference manuals, policies and procedures made available to you or your employer by Delta Dental, for complete details of your rights and obligations. Should any discrepancy arise, any such contract(s) and other such document(s) supersede this illustration. Orthodontic Payments Delta Dental s orthodontic payment is calculated in the same manner as the Delta Dental Payment in the above examples. How to Submit a Claim If you see a dentist who is in the Delta Dental PPO or the Delta Dental Premier network, the dentist will fill out and submit claim paperwork. If you choose to see an out-of-network dentist, you may need to pay the dentist directly and then submit a claim form to us. For your convenience, you can print a claim form from our website: (Some out-of-network dentists may also provide this service upon your request.) Delta Dental shall not be obligated to pay claims submitted more than twelve (12) months after the date of the service, unless it can be shown not to have been reasonably possible to submit the claim and the claim was submitted as soon as reasonably possible. For services completed by an out-ofnetwork dental provider, completely fill out a claim form and mail it to: Delta Dental P.O. Box 249 Thiensville, WI You may also fax your completed claim form to Please write Attn: Claims at the top Payment Guidelines Delta Dental does not pay participating dentists any incentive as an inducement to deny, reduce, limit or delay any appropriate service. If you or your dentist files a claim for services more than twelve (12) months after the date you received the services, payment may be denied. If the services were received from an out-ofnetwork dentist, you are still responsible for the full cost. If the payment is denied because your participating dentist failed to submit the claim on time, you may not be responsible for that payment. However, if you did not tell your participating dentist that you were an enrollee of 9 P a g e

12 the plan at the time you received the service, you may be responsible for the cost of that service. We explain to all participating dentists how we determine or deny payment for services. If any claims are not covered, or if limitations or exclusions apply to services you have received, you may be responsible for the full payment. If you have questions about any dental charges, processing policies and/or how your claim is paid, contact Delta Dental at Optional Treatment and Non-Covered Services You must pay for any non-covered or optional dental benefits that you choose to have done. Refer to the Qualifications section of your benefit plan summary and/or the Limitations and Exclusions section of this document for information about excluded services and limitations. A dentist may use different methods or approaches to treat dental needs. Your plan generally covers dental treatment using standards of care consistent with the delivery of quality, affordable dental treatment to the enrollee. If you request a treatment that is more costly than standard practice, you must pay for the charges in excess of the covered dental benefit. Example: If a metal filling would fix the tooth and you choose to have the tooth crowned, you are responsible for paying the difference between the cost of the crown and the cost of the filling. You must pay this money directly to your dentist. Pre-Treatment Estimates A pre-treatment estimate is a claim form submitted by your dentist before performing the service. When the pre-treatment estimate is processed, you will receive an estimate of your share of the cost and how much Delta Dental will pay before treatment begins. If you and your dentist are unsure of your benefits for a specific course of treatment, Delta Dental recommends that you ask for a pretreatment estimate. It is suggested that Delta Dental network dentists give their patients a pretreatment estimate if treatment costs are expected to exceed $300. Pre-treatment estimate requests are not required, but may be submitted for more complicated and expensive procedures such as crowns, wisdom tooth extractions, bridges, dentures, or periodontal surgery. Delta Dental will act promptly in returning a pre-treatment estimate to you and the attending dentist with non-binding verification of your current availability of benefits and applicable maximums. The pre-treatment estimate is nonbinding as the availability of benefits may change subsequent to the date of the estimate due to a change in eligibility status, exhaustion of applicable maximum benefit, or application of frequency of procedure limitations. Other Health Insurance Be sure to advise your dentist of all programs under which you have dental coverage, and have the dentist complete the dual coverage portion of the claim form so that you will receive all benefits to which you are entitled. When you have dental coverage under more than one benefit program (e.g. if you and your spouse both get dental coverage), the carriers coordinate the two programs. This is sometimes called coordination of benefits. One carrier is deemed the primary and the other is the secondary. The primary carrier pays its portion first and then the secondary carrier pays its portion, not to exceed the difference between the allowed amount of the first plan and the allowed amount of the second plan for the covered services. 10 P a g e

13 ELIGIBILITY AND ENROLLMENT Eligibility Requirements You will become eligible to receive benefits on the date stated in the contract after completing any eligibility periods required by your employer. You may enroll for individual and family coverage. If your dependents are covered, they will be eligible when you are or as soon as they become dependents. Dependents may be your: Spouse Children until the end of the month of their 19th birthday. Such children may include: (a) your biological child (b) your legally adopted child (including a child living with the adopting parents and/or grandparents during the period of probation) (c) a child for whom you have legal guardianship or temporary guardianship of more than 12 months duration and for a shorter period if the guardianship is of a dependent minor and granted by testamentary, (d) a stepchild Documentation of the above must be furnished upon request by Delta Dental. Children who are full-time students in a bona fide educational institution until the end of the month of their 23rd birthday. Children of any age who are incapable of self-support by reason of mental or physical incapacity that occurred before the age of 19 or 23 if a full-time student (to the end of the month) and were covered prior to age 19 or 23 if a full-time student (to the end of the month). The dependent child must also be chiefly dependent on you for support and maintenance, but is not required to reside with a parent or legal guardian who is a primary enrollee. Eligibility of these dependent children will not be terminated while the contract remains in force and the dependent child remains in such condition. * Effective 10/01/2015 dependent children are covered to age 26 regardless of status. Newborn children of any primary enrollee for 31 days from: (a) the moment of birth, (b) the date of placement for adoption or upon placement in the foster home, or (c) the date of appointment for a minor for whom guardianship has been granted by court or testamentary appointment. Proof of birth or adoption or foster home placement must be furnished upon request by Delta Dental. In order for the coverage to continue beyond the 31-day period, you must notify the Plan administrator of the birth, adoption, placement in the foster home, or appointment of guardianship. Changes in Eligibility Status Changes in your eligibility status (i.e. marriage, divorce, birth, graduation, etc.) must be reported to your Plan Administrator (e.g. your HR Director) within 30 days following the event causing the change. If you do not change coverage when first eligible, you may change later during a subsequent open enrollment period. 11 P a g e

14 Changes typically become effective on the exact day of notification of the change. Loss of Eligibility Your coverage ends on the last day of the month in which termination of employment occurs or immediately when this program ends. Coverage for all dependents also ceases at that time, or when dependent status is lost. Your dependent children will be disqualified for benefits at the end of the month when they reach the disqualifying age. COMPLAINTS, GRIEVANCES AND APPEALS Our commitment to you is to ensure quality throughout the entire treatment process: from the courtesy extended to you by our customer service representatives to the dental services provided by our participating dentists. If you have questions about any services received, we recommend that you first discuss the matter with your dentist. However, if you continue to have concerns, please call Delta Dental s Customer Service Center. Delta Dental attempts to process all claims within 30 days. If a claim will be delayed more than 30 days, Delta Dental will notify you in writing within 30 days stating the reason for delay. Questions or complaints regarding eligibility, the denial of dental services or claims, the policies, procedures, or operations of Delta Dental, or the quality of dental services performed by the dentist, may be directed in writing to Delta Dental or by calling Delta Dental at or toll-free at A grievance is a written expression of dissatisfaction with the provision of services or claims practices of Delta Dental. When you write, please include the name of the enrollee, the primary enrollee s name and ID, and your telephone number on all correspondence. You should also include a copy of the claim form, benefits statement, invoice or other relevant information. Appeals You have the right to dispute our decision to deny, reduce, modify or disallow payment of dental benefits. Please note: All decisions made by Delta Dental are in accordance with each the provisions of your dental plan contract provisions and limitations, Delta Dental policies and any applicable law. Appeals of claims that have been denied must be submitted in writing using the Appeal Request form. Send your completed Appeal Request Form to Delta Dental at the address shown below: Delta Dental Attention Appeals P.O. Box 9695 Boston, MA Alternately, you may also fax the completed form to Within five business days of receiving your appeal request, we will send you a confirmation letter. This letter will describe the appeal process and member rights. Customarily, a decision will be reached on the appeal within 30 days. 12 P a g e

15 ADDITIONAL IMPORTANT INFORMATION Proof of Claim Before approving a claim, Delta Dental is entitled to receive, to such extent as may be lawful, from any attending or examining dentist, or from hospitals in which a dentist s care is provided, such information and records relating to attendance to or examination of, or treatment provided to an enrollee, as may be required to administer the claim, or that an enrollee be examined by a dental consultant retained by Delta Dental, in or near the community or residence. Delta Dental will in every case hold such information and records confidential. Physical Access Delta Dental has made efforts to ensure that its offices and the offices and facilities of participating dentists are accessible to individuals with mobility impairments. If you are not able to locate an accessible dentist, please call our Customer Service Center and a customer service representative will help you find an alternate dentist. DEFINITIONS AND TERMS Adverse Determination A decision by Delta Dental to deny, reduce, or modify the availability of any dental care services, because your condition failed to meet the requirements for coverage based on necessity, appropriateness of care, level of care, or effectiveness. Allowable Charge The fees, on which program deductibles, maximums, and coinsurance percentage are based, that a dental program will reimburse a dentist for a service as defined by a contract. This is also referred to as the maximum plan allowance or maximum allowable charge. Dentists have agreed to accept a maximum plan allowance based on the agreements they have signed with Delta Dental. This does not apply to out-of-network dentists. Benefit Summary An overview of an enrollee s dental benefit program, usually including co-payment percentages, deductibles, maximums, and noncovered services, often used at open enrollments. Carrier Delta Dental member companies include dental benefits carriers, dental carriers, health carriers, service corporations, and service plans. The majority of Delta Dental organizations are licensed as specialized health care service plans. Claim or Claim Form Information submitted by a dentist or enrollee to establish that services were provided to an enrollee; this data is the basis from which processing for payment to the dentist or enrollee is made. A dentist is responsible for the accuracy of all information on a claim form. Claim forms can be submitted to carriers on paper or electronically. Coinsurance The percentage of the costs of services paid by the patient (e.g. 20% of minor restorative services). This is a characteristic of indemnity insurance, POS, and PPO plans. Complaint Any inquiry made by you or on your behalf to Delta Dental that is not explained or resolved to your satisfaction within ten (10) business days of the inquiry; or involves an adverse determination. Coordination of Benefits When a person is covered by more than one benefit plan (for example, a child who is covered by both parents programs), the two sets of benefits are coordinated so that no more than 100 percent of the total covered expense is paid. Covered Individual A person who receives dental benefits from Delta Dental. Usually includes subscribers and their dependents. 13 P a g e

16 Covered Services Services for which payment is provided under the terms of the dental benefits contract. Date of Service The actual date that a service was completed. With multi-stage procedures, the date of service is the final completion date (the insertion date of a denture, for example). Deductible The portion of the covered dental expenses that the subscriber must pay before the plan s payment begins. The deductible plus the copayment and amount over the annual maximum are often referred to as the enrollee s out-of-pocket costs. Under Delta Dental benefit plans, diagnostic and preventive services are often exempt from a deductible. Diagnostic and Preventive Procedures In the standard client contract, these procedures include oral examinations, cleanings, x-rays, fluoride treatments, and space maintainers. Dual Coverage When an enrollee has coverage under more than one benefit plan, the primary and secondary carriers coordinate the two plans so that the primary carrier pays its portion first and the secondary carrier may pay the remainder. See Coordination of Benefits and Non-duplication of Benefits. Enrollee A person covered under a Delta Dental plan. Enrollees includes both subscribers and their covered dependents. Sometimes referred to as a member. Explanation of Benefits (EOB) The notice enrollees receive after a claim is processed. The EOB provides information about the fees charged, what procedures were provided, and the enrollee s payment portion. Fracture The breaking off of rigid tooth structure not including crazing due to thermal changes or chipping due to attrition. Grievance Refers to any oral or written complaint submitted to Delta Dental by you or on your behalf concerning any aspect or action of Delta Dental. This is including, but not limited to, review of adverse determinations regarding the scope of your coverage, denial of services, quality of care and administrative operations. In-network Term used to describe a participating dentist or a service provided by a participating dentist. See Network. Inquiry Means any question or concern communicated by you or on your behalf to Delta Dental, which has not been the subject of an adverse determination. Limitations/Exclusions Services that are limited or excluded from a dental benefit plan. The enrollee is usually responsible for the fee for services that are not benefits of the dental benefit plan. These services are called optional services. Maximum/Annual Maximum/Maximum Benefit The maximum payment Delta Dental will make within a given time period. Some plans have no maximum. Some maximums apply to the lifetime of the benefit plan; others apply to a particular time period (calendar year, benefit year, etc.) or to particular services (such as a separate maximum for orthodontic benefits). Network The organization of dentists who have agreed to provide treatment within certain administrative guidelines for certain programs (participating dentists). The Delta Dental Premier, Delta Dental PPO programs all have distinct dentist networks. Sometimes referred to as a panel. Non-participating Dentist Any dentist who does not have a contractual agreement with Delta Dental to provide dental services to enrollees of a Delta Dental benefit plan. Also referred to as out-of-network. 14 P a g e

17 Out-of-network Term used to describe a non-participating dentist or a service provided by a non-participating dentist. See Network. Out-of-pocket costs The portion of dental fees that the enrollee pays. Depending on the circumstances, it may include a coinsurance, a deductible, and any amount exceeding the plan s maximum and optional services not covered by the plan. PPO (preferred provider organization) A PPO is a fee-for-service program that allows enrollees to choose any dentist, but provides financial incentives to choose lower-priced dentists who are part of the PPO network. Delta Dental s PPO is called Delta Dental PPO. Provider A dentist or other practitioner, such as a dental hygienist. Specialist A dentist who has received advanced training and is certified in one of the recognized dental specialties: endodontics, orthodontics, oral surgery, pediatric dentistry, periodontics, and prosthodontics. Subscriber Subscribers are the persons counted in a group (generally employees or members of the group). Enrollees include both subscribers and their covered dependents. See Enrollee. 15 P a g e

18 DELTA DENTAL OF MASSACHUSETTS Medford Street Boston, MA 02129

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