CARE ACCESS (HMO) DENTAL HANDBOOK AZCNTPLUSDNT18_1 Y0114_18_33866_U_002 CMS Accepted
Are my cleanings covered? FREQUENTLY ASKED QUESTIONS Yes. Your dental coverage includes two (2) routine cleanings (prophylaxis) by your Dentist every year, for $0 copayment. Some members may require more than a routine cleaning due to more involved dental needs. When extensive treatment (such as root planing or scaling) is required, your dentist may charge you in accordance with your dental plan. What if I have a pre-existing condition? Most pre-existing conditions are covered. However, a procedure started prior to your coverage effective date will not be covered. For example, if a dentist has started a crown prior to your effective date with LIBERTY Dental Plan, LIBERTY will not pay for completion of that crown. Does the Plan include dental specialists? Yes. The Dental Plan has a contracted network of dental specialists. If specialty care is deemed necessary by your Dentist, you will be referred to a specialist after coordinating your needs with your Dentist. How will I know what my copayment will be? Refer to the Schedule of Benefts in this handbook. The Schedule of Benefts lists all of the covered services. The copayment schedule is listed by American Dental Association (ADA) code. If you have any questions, ask your dentist before you receive services and/or call the Member Services Department. Who do I call if I have a question? Should you have questions once you become a member, please contact Member Services at 1-888-816-2790 (TTY users should call 711). Hours are 8:00 a.m. 8:00 p.m., 7 days a week from October 1 to February 14 (except Thanksgiving and Christmas), and 8:00 a.m. 8:00 p.m., Monday Friday (except holidays) from February 15 to September 30. Member Services representatives can speak multiple languages and can access interpreting services upon request. They are committed to helping members with questions regarding how to make a dental appointment, eligibility, benefts and what to expect in the dental offce. For general inquiries, contact: Member Services 1-888-816-2790 TTY/TDD: 711 8:00 a.m. to 8:00 p.m. Seven days a week (October 1 through February 14, except Thanksgiving and Christmas) Monday Friday, except holidays (February 15 through September 30) ii
We are pleased to offer the LIBERTY Dental Plan to our members. This handbook explains the LIBERTY Dental Plan and its many advantages. Your Dental Plan There is no deductible for this plan. Covered services include diagnostic, preventive, radiographs and comprehensive dental services. Please refer to the beneft schedule starting on page 4 for a complete list of covered dental services. You can begin using your dental benefts on your Health Plan membership effective date. You will receive a dental membership card from LIBERTY Dental in the mail. There are no additional forms to complete. Eligibility Rules You are eligible for this dental plan if you are a member of CareMore Care Access (HMO). Effective Date Membership will become effective on the frst day of the month following our receipt of your CareMore health plan application and premium. Choose Your Primary Care Dentist To choose or change your Primary Care Dentist, please call Member Services at 1-888-816-2790 (TTY users should call 711). Hours are 8:00 a.m. 8:00 p.m., 7 days a week from October 1 to February 14 (except Thanksgiving and Christmas), and 8:00 a.m. 8:00 p.m., Monday Friday (except holidays) from February 15 to September 30. You may change your Primary Care Dentist for any reason. If requested by the 20th of the month, your change in your Primary Care Dentist will become effective the frst of the following month. In case of emergencies, we will work to make the change effective immediately. You will receive a new membership card showing the name and phone number of your new Primary Care Dentist. 1
Your Dental Membership Card When receiving dental services, you must use your dental membership card. Here is a sample membership card to show you what yours will look like: Front Side Back Side dddd Member Name: First M. Last Member ID: Plan: Effective Date: 1/1/2013 PRV: PRV Phone Number: LIBERTY Dental Plan www.caremore.com SAMPLE If you have a dental emergency, you should first contact your Primary Care Dentist for an immediate appointment. If your Primary Care Dentist is not available, contact CareMore Member Services Member for Services assistance. for assistance. Please refer Please to your refer to your Evidience Evidence of Coverage of Coverage for specifc for specific emergency emergency care care coverage. Specialty services must be authorized. CareMore Member Member Services: Services: 1-888-816-2790 1-800-499-2793 TTY users call: 711 Monday Friday: 8:00 a.m. - 8:00 p.m. This Card Does Guarantee Eligibility SAMPLE If your membership card is damaged, lost, or stolen, please call us right away for a replacement card. HOW TO RECEIVE CARE Remember to always check with your dental offce before receiving services to make sure the offce is your assigned Dental Plan provider. You must choose a Primary Care Dentist when you enroll in the plan. You can change dentists at anytime by calling Member Services or by submitting a request for provider change in writing. Your Provider Directory has a list of dental providers or you can visit http://arizona.caremore.com/. A change to your Primary Care Dentist must be requested before the 20th day of the month to be effective the frst of the following month. IMPORTANT: As a member of Care Access (HMO), you must choose your LIBERTY Dental Plan provider from the list of Connect Plus Dental Providers listed in your Provider / Pharmacy Directory. You cannot select a dentist from the Basic Dental Provider list. However, you may want to consider a choice convenient to your residence or work. As a member, you should be able to make an appointment to be seen for dental hygiene and routine care within three weeks of the date of your request. This is based upon available schedule times. HOW TO MAKE AN APPOINTMENT Call your Primary Care Dentist listed on your LIBERTY Dental membership card. Identify yourself as a member of LIBERTY Dental Plan and schedule your appointment. We also suggest that you keep this material handy and take this information with you when you go to your appointment. You can then reference benefts and applicable copayments which are the out-of-pocket costs associated with your plan. 2
HOW TO FILE A CLAIM FORM There are no claim forms to worry about with your plan. LIBERTY Dental Plan prepays Plan Primary Care Dentists in advance for covered services (less applicable copayments of your plan). Customer Service If you have a question regarding dental inquiries, eligibility, claims or precertifcation, please call Member Services at 1-888- 816-2790 (TTY users should call 711). Hours are 8:00 a.m. 8:00 p.m., 7 days a week from October 1 to February 14 (except Thanksgiving and Christmas), and 8:00 a.m. 8:00 p.m., Monday Friday (except holidays) from February 15 to September 30. 3
LIBERTY Dental Plan SCHEDULE OF BENEFITS Covered Benefts & Member Copayments No Annual Deductible Member copayments are payable to the dental offce at the time services are rendered. This Schedule does not guarantee benefts. All services are subject to eligibility and dental necessity at the time of service. Dental procedures not listed as covered benefts are available at the dental offce s usual and customary fee. The following is a complete list of dental procedures for which benefts are payable under this Plan. Any procedures not listed will apply to plan maximum as listed below. This Plan does not allow alternate benefts. The member must visit a contracted dental offce to utilize covered benefts. CODE OPTION F + COMP* MEMBER COPAYMENT D0120 D0150 2 Exams/ Year $0 D1110 2 Cleanings/ Year $0 D0210 D0330 1 FMX or Pano/ Year $0 *$50 quarterly allowance covers any CDT code Unused quarterly allowance will rollover into the following quarter but will not rollover into January 1, 2019. LIBERTY Dental Plan will arrange for you to receive services from a contracted Dental Specialist if the necessary treatment is outside the scope of General Dentistry. Your General Dentist will initiate the referral process with LIBERTY Dental Plan. When you receive services from a Dental Specialist utilizing the proper referral process, the Member Copayments listed in this Copayment Schedule will apply. 4
Prior Authorization No prior beneft authorization is required in order to receive dental services from your Primary Care Dentist. Your Dentist has the authority to make most coverage determinations. Coverage determinations are achieved through oral evaluations. Your Dentist is responsible for communicating the results of the oral evaluation and advising you of available benefts and any associated cost. If your Dentist encounters a situation that requires the services of a specialist, LIBERTY Dental Plan requires a preauthorization submission, which will be responded to within fve (5) business days of receipt, unless urgent. If you or your Dentist encounter an urgent condition in which there is 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 the normal time frame for the decision making process as described above would be detrimental to your life or health, the response to the request for referral should not exceed twenty-four (24) hours from the time of receipt of such information. The decision to approve, modify or deny will be communicated to the Dentist within twenty-four (24) hours of the decision. In cases where the review is retrospective, the decision shall be communicated to you within thirty (30) days of the receipt of the information. Authorization needs to be obtained prior to receiving services from a specialist. Your Dentist is responsible for obtaining authorization for you to receive specialty care. Emergency Dental Care The plan provides coverage for emergency dental services only if the services are required to alleviate severe pain or bleeding, or if you reasonably believe that the condition, if not diagnosed or treated, may lead to disability, dysfunction or permanent damage to your health. Emergency dental services and care which are covered by the Dental Plan include a dental screening, an examination, an evaluation by a dentist or a dental specialist to determine if an emergency dental condition exists, and to provide care that would be acknowledged as within professionally recognized standards of care and in order to alleviate any emergency symptoms in a dental offce. Medical and/or psychiatric emergencies are not covered by the Dental Plan. If services are rendered in a hospital setting and/or if LIBERTY determines services were not dental in nature, the services will not be covered by LIBERTY Dental. How to Obtain Emergency Dental Care In the event you require emergency dental care, contact your Dentist to schedule an immediate appointment. For urgent or unexpected dental conditions that occur after hours or on weekends, contact your Dentist for instructions on how to proceed. Your dentist will provide emergency information on their phone line after hours and on weekends -- and will have an answering machine for you to leave messages. If you are unable to get in touch with your Primary Care Dentist, LIBERTY Dental also provides an after hours and weekend service where messages are taken and forwarded directly to our dental director. Just call 1-888-703-6999 to contact LIBERTY s after hours line. 5
Reimbursement for Emergency Dental Care If the requirements in the Emergency Dental Care section are satisfed, the Dental Plan will cover up to $75 for such services per calendar year. If you pay a bill for covered emergency dental care, submit a copy of the paid bill to the address below: LIBERTY Dental Plan Claims Department P.O. Box 26110 Santa Ana, CA 92799-6110 Please include a copy of the claim from the provider offce or a statement of services and/or invoice. Please forward your copy or statement to LIBERTY Dental Plan with the following information: Your membership information Name and address of the dentist who provided the emergency dental care A statement explaining the circumstances surrounding the emergency visit If additional information is needed, you will be notifed in writing. If any part of your claim is denied, you will receive a written explanation of benefts (EOB) within 30 days of the Dental Plan s receipt of the claim. Your EOB will include the following information: Reason for denial Reference to pertinent Dental Handbook provisions on which the denial is based Notice of your right to request a reconsideration of the denial and an explanation of the grievance process Continuity of Care Current Members If a LIBERTY Dental Plan provider is terminated, current members may have the right to the completion of care with the terminated provider for certain specifed dental conditions. Please contact the Dental Plan to see if you may be eligible for this beneft. You must make a specifc request to continue under the care of your terminated provider. We are not required to continue your care with that provider if you are not eligible under our policy or if we cannot reach an agreement with your terminated provider on the terms regarding your care. New Members A new member may have the right to the completion of care with a non-participating provider for certain specifed dental conditions. Please contact the Dental Plan to see if you may be eligible for this beneft. You must make a specifc request to continue under the care of your current provider. We are not required to continue your care with that provider if you are not eligible under our policy or if we cannot reach an agreement with your provider on the terms regarding your care. 6
Second Opinion You may request a second dental opinion, when appropriate, by contacting Member Services at 1-888-816-2790 (TTY users should call 711). Hours are 8:00 a.m. 8:00 p.m., 7 days a week from October 1 to February 14 (except Thanksgiving and Christmas), and 8:00 a.m. 8:00 p.m., Monday Friday (except holidays) from February 15 to September 30. You may also send a written request to: LIBERTY Dental Plan P.O. Box 26110 Santa Ana, CA 92799-6110 Your Dentist may also request a second dental opinion on your behalf by submitting a request with appropriate X-rays. All requests for a second dental opinion are approved by the Dental Plan within fve (5) days of receipt of such request. Upon approval, the Dental Plan will make the appropriate second dental opinion arrangements and advise the attending dentist of your concerns. You will then be advised of the arrangement so an appointment can be scheduled. Upon request, you may obtain a copy of the Dental Plan s policy description for a second dental opinion. Complaint Process For complete details about your rights to fle a complaint, please see your Health Plan s Evidence of Coverage. The benefts described in this handbook are subject to the same complaint process. Appeal Process Any disputes regarding the dental program may be subject to the our appeal process, which may be found in our Health Plan s Evidence of Coverage. The benefts described in this handbook are subject to the same appeal process. Termination of Coverage Dental Plan coverage can be terminated for a number of reasons. The Plan will give 45 days advance written notice of coverage termination for the reasons listed below. Coverage will end on the last day of the month following the date of the 45-day notice. The reasons include: 1. The Member commits any action of fraud or material misrepresentation in applying for or seeking any benefts under this Plan. 2. The Member exhibits disruptive, unruly, abusive, unlawful, fraudulent or uncooperative behavior towards a dental provider or administrative staff that seriously impairs the Plan s ability to provide services to the Member and/or to other Members; 3. The Member misuses the documents provided as evidence of benefts available under this Plan, including the Member Identifcation Card. 1. The Member furnishes incorrect or incomplete information for the purpose of fraudulently obtaining services. 2. The Member leaves the Plan s Service Area with the intention to relocate or establish a new residence. (45 day advance written notice of coverage termination does not apply to this reason.) 7
The Plan can also discontinue your membership if you do not pay your premium. If you do not pay all premiums in full, you will be disenrolled from the Plan. The disenrollment will be effective the frst month following a 90-day grace period after we send you a notice of non-payment. When you are no longer a member, your Dental Plan coverage will also end. Limitations & Exclusions Limitations: 1. Prophylaxis are covered twice per calendar year. 2. Full Mouth X-rays are limited to once every year Exclusions: 1. Any procedure not specifcally listed as a Covered Beneft. 2. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliances. 3. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a beneft. 4. Procedures considered experimental, treatment involving implants or pharmacological regimens other than listed as Covered Beneft (see Independent Medical Review in the Evidence of Coverage and Disclosure Form). 5. Oral surgery requiring the setting of bone fractures or bone dislocations. 6. Hospitalization. 7. Outpatient services. 8. Ambulance services. 9. Durable Medical Equipment. 10. Mental Health services. 11. Chemical Dependency services. 12. Home Health services. 13. General anesthesia, analgesia, intravenous/intramuscular sedation or the services of an anesthesiologist other than listed as Covered Beneft. 14. Treatment started before the member was eligible, or after the member was no longer eligible. 15. Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorder, including but not limited to: myofunctional(e.g. speech therapy), myoskeletal, or temporomandibular joint dysfunctions (e.g. adjustments/corrections to the facial bones) unless otherwise covered as an orthodontic beneft. 16. Procedures which are determined not to be dentally necessary consistent with professionally recognized standards of dental practice. 17. Treatment of malignancies, cysts, or neoplasms. 18. Orthodontic treatment started prior to member s effective date of coverage. 19. Appliances needed to increase vertical dimension or restore occlusion. 20. Any services performed outside of your Primary Care Dentist s offce, unless expressly authorized by Liberty Dental Plan, or unless as outlined and covered in Emergency Dental Care section. 8
Disclaimers CareMore is an HMO plan with a Medicare contract. Enrollment in CareMore depends on contract renewal. You must receive all routine care from network providers. Exceptions are in emergency or urgent care situations. If you obtain routine care from out-of-network providers, neither Medicare, your health plan nor LIBERTY will be responsible for the costs. NOTICE OF NON-DISCRIMINATION We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We: Provide free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provide free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services, Appeals & Grievances, 12900 Park Plaza Drive, Suite 150, Mailstop 6150, Cerritos, CA 90703, 1-888-816-2790, TTY 711. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Member Services Representative is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/ index.html. Amharic 1-888-816-2790 711 Arabic Armenian 711 1-888-816-2790 Bengali 9
Chinese English French ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-816-2790 711 German Hindi Hmong Ilocano Japanese 1-888-816-2790 Korean Kru (Bassa) Mon-Khmer, Cambodian Navajo Persian (Farsi) (TTY: 711) 1-888-816-2790 Punjabi Russian Samoan Serbo-Croatian 1-888-816-2790 711 1-888-816-2790 711 10
Spanish Syriac.(TTY: 711) 1-888-816-2790 Tagalog Thai Urdu : Vietnamese 11 NOND_AZ