Common use of Adverse Benefit Determinations and Appeals Clause in Contracts

Adverse Benefit Determinations and Appeals. We may review dental necessity on a case-by-case basis. WE DETERMINE DENTAL NECESSITY SOLELY FOR PURPOSES OF CLAIMS PAYMENT IN ACCORDANCE WITH OUR DENTAL POLICIES AND RELATED GUIDELINES UNDER THIS AGREEMENT. PREDETERMINATION is an administrative procedure whereby your dentist sends to us your treatment plan before treatment is rendered. Predeterminations are an estimate, not a guarantee of payment. The predetermination estimates are based on your eligibility status and benefits at the time the request is processed. It is subject to change. Obtaining predetermination is NOT a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination is that the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network or non-network dentist. You have the right to appeal or to take legal action as described in Section 7.0. Network dentists may get predetermination for all covered dental care services. This includes, but is not limited to, multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures) and orthodontics. When your dentist is non-network, you or the non-network dentist may obtain a predetermination. You may inquire about