Common use of Financial Responsibility for Continuity of Care Services Clause in Contracts

Financial Responsibility for Continuity of Care Services. If a Member is entitled to receive Services from a terminated provider under the preceding Continuity of Care provision, the responsibility of the Member to that provider for Services rendered under the Continuity of Care provision shall be no greater than for the same Services rendered by a Participating Dentist in the same geographic area. Pre-certification of Dental Benefits Before any course of treatment expected to cost more than $250 is started, you should obtain Pre-certification of Benefits. Your Dentist should submit the recommended treatment plan and fees together with appropriate diagnostic X-rays to a contracted Dental Plan Administrator. A contracted Dental Plan Administrator will review the dental treatment plan to determine the benefits payable under the plan. The benefit determination for the proposed treatment plan will then be promptly returned to the Dentist. When the treatment is completed, your claim form should be submitted to a contracted Dental Plan Administrator for payment determination. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. The dental plan provides benefits for covered services at the most cost-effective level of care that is consistent with professionally recognized standards of care. If there are two or more professionally recognized procedures for treatment of a dental condition, this plan will in most cases provide benefits based on the most cost-effective procedure. The benefits provided under this plan are based on these considerations but you and your Dentist make the final decision regarding treatment. Failure to obtain Pre-certification of Benefits may result in a denial of benefits. If the Pre-certification process is not followed, a contracted Dental Plan Administrator will still determine payment by taking into account alternative procedures; services or materials for the dental condition based on professionally recognized standards of dental practice. However, by following the Pre-certification process both you and your Dentist will know in advance which services are covered and the benefits that are payable. The covered dental expense will be limited to the Allowable Amount for the procedure, service or material which meets professionally recognized standards of quality dental care and is the most cost effective as determined by a contracted Dental Plan Administrator. If you and your Dentist decide on a more costly procedure, service or material than a contracted Dental Plan Administrator determined is payable under the plan, then benefits will be applied to the selected treatment plan up to the benefit maximum for the most cost effective alternative. You will be responsible for any charges in excess of the benefit amount. A contracted Dental Plan Administrator reserves the right to use the services of dental consultants in the Pre- certification review. Example: 🞟 If a crown is placed on a tooth which can be restored by a filling, benefits will be based on the filling; 🞟 If a semi-precision or precision partial denture is inserted, benefits may be based on a conventional clasp partial denture 🞟 If a bridge is placed and the patient has multiple unrestored missing teeth, Benefits will be based on a partial denture. Participating Dentists When you receive covered dental services from a Participating Dentist, you will be responsible for a coinsurance amount as outlined in the section entitled Summary of Benefits. Participating Dentists will file claims on your behalf. Participating Dentists will be paid directly by the plan, and have agreed to accept a contracted Dental Plan Administrator’s payment, plus your payment of any applicable deductible or coinsurance amount, as payment in full for covered services. If the covered Member recovers from a third party the reasonable value of covered services rendered by a Participating Dentist, the Participating Dentist who rendered these services is not required to accept the fees paid by a contracted Dental Plan Administrator as payment in full, but may collect from the covered Member the difference, if any, between the fees paid by a contracted Dental Plan Administrator and the amount collected by the covered Member for these services. Non-Participating Dentists Services received from a Non-Participating Dentist are not covered. When you receive covered services from a Non- Participating Dentist, you will be responsible for paying the Dentist directly for the entire amount billed by the Dentist. Procedure for Filing a Claim Claims for covered dental Services should be submitted on a dental claim form which may be obtained from the contracted Dental Plan Administrator or at xxxxxxxxxxxx.xxx. Have your Dentist complete the form and mail it to the contracted Dental Plan Administrator Service Center shown on the last page of this booklet. A contracted Dental Plan Administrator will provide payment in accordance with the provisions of this Agreement. You will receive an explanation of benefits after the claim has been processed. All claims for reimbursement must be submitted to a contracted Dental Plan Administrator within one (1) year after the month in which the service is rendered. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim.

Financial Responsibility for Continuity of Care Services. If a Member is entitled to receive Services from a terminated provider under the preceding Continuity of Care provision, the responsibility of the Member to that provider for Services rendered under the Continuity of Care provision shall be no greater than for the same Services rendered by a Participating Dentist in the same geographic area. Pre-certification of Dental Benefits Before any course of treatment expected to cost more than $250 is started, you should obtain Pre-certification of Benefits. Your Dentist should submit the recommended treatment plan and fees together with appropriate diagnostic X-rays to a contracted Dental Plan Administrator. A contracted Dental Plan Administrator will review the dental treatment plan to determine the benefits payable under the plan. The benefit determination for the proposed treatment plan will then be promptly returned to the Dentist. When the treatment is completed, your claim form should be submitted to a contracted Dental Plan Administrator for payment determination. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. The dental plan provides benefits for covered services at the most cost-effective level of care that is consistent with professionally recognized standards of care. If there are two or more professionally recognized procedures for treatment of a dental condition, this plan will in most cases provide benefits based on the most cost-effective procedure. The benefits provided under this plan are based on these considerations but you and your Dentist make the final decision regarding treatment. Failure to obtain Pre-certification of Benefits may result in a denial of benefits. If the Pre-certification process is not followed, a contracted Dental Plan Administrator will still determine payment by taking into account alternative procedures; services or materials for the dental condition based on professionally recognized standards of dental practice. However, by following the Pre-certification process both you and your Dentist will know in advance which services are covered and the benefits that are payable. The covered dental expense will be limited to the Allowable Amount for the procedure, service or material which meets professionally recognized standards of quality dental care and is the most cost effective as determined by a contracted Dental Plan Administrator. If you and your Dentist decide on a more costly procedure, service or material than a contracted Dental Plan Administrator determined is payable under the plan, then benefits will be applied to the selected treatment plan up to the benefit maximum for the most cost effective alternative. You will be responsible for any charges in excess of the benefit amount. A contracted Dental Plan Administrator reserves the right to use the services of dental consultants in the Pre- certification review. Example: 🞟 If a crown is placed on a tooth which can be restored by a filling, benefits will be based on the filling; � � If a semi-precision or precision partial denture is inserted, benefits may be based on a conventional clasp partial denture  🞟 If a bridge is placed and the patient has multiple unrestored missing teeth, Benefits will be based on a partial denture. Participating Dentists When you receive covered dental services from a Participating Dentist, you will be responsible for a coinsurance amount as outlined in the section entitled Summary of Benefits. Participating Dentists will file claims on your behalf. Participating Dentists will be paid directly by the plan, and have agreed to accept a contracted Dental Plan Administrator’s payment, plus your payment of any applicable deductible or coinsurance amount, as payment in full for covered services. If the covered Member recovers from a third party the reasonable value of covered services rendered by a Participating Dentist, the Participating Dentist who rendered these services is not required to accept the fees paid by a contracted Dental Plan Administrator as payment in full, but may collect from the covered Member the difference, if any, between the fees paid by a contracted Dental Plan Administrator and the amount collected by the covered Member for these services. Non-Participating Dentists Services received from a Non-Participating Dentist are not covered. When you receive covered services from a Non- Participating Dentist, you will be responsible for paying the Dentist directly for the entire amount billed by the Dentist. Procedure for Filing a Claim Claims for covered dental Services should be submitted on a dental claim form which may be obtained from the contracted Dental Plan Administrator or at xxxxxxxxxxxx.xxx. Have your Dentist complete the form and mail it to the contracted Dental Plan Administrator Service Center shown on the last page of this booklet. A contracted Dental Plan Administrator will provide payment in accordance with the provisions of this Agreement. You will receive an explanation of benefits after the claim has been processed. All claims for reimbursement must be submitted to a contracted Dental Plan Administrator within one (1) year after the month in which the service is rendered. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim.

Financial Responsibility for Continuity of Care Services. If a Member is entitled to receive Services from a terminated provider under the preceding Continuity of Care provision, the responsibility of the Member to that provider for Services rendered under the Continuity of Care provision shall be no greater than for the same Services rendered by a Participating Dentist in the same geographic area. Pre-certification of Dental Benefits Before any course of treatment expected to cost more than $250 is started, you should obtain Pre-certification of Benefits. Your Dentist should submit the recommended treatment plan and fees together with appropriate diagnostic X-rays to a contracted Dental Plan Administrator. A contracted Dental Plan Administrator will review the dental treatment plan to determine the benefits payable under the plan. The benefit determination for the proposed treatment plan will then be promptly returned to the Dentist. When the treatment is completed, your claim form should be submitted to a contracted Dental Plan Administrator for payment determination. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. The dental plan provides benefits for covered services at the most cost-effective level of care that is consistent with professionally recognized standards of care. If there are two or more professionally recognized procedures for treatment of a dental condition, this plan will in most cases provide benefits based on the most cost-effective procedure. The benefits provided under this plan are based on these considerations but you and your Dentist make the final decision regarding treatment. Failure to obtain Pre-certification of Benefits may result in a denial of benefits. If the Pre-certification process is not followed, a contracted Dental Plan Administrator will still determine payment by taking into account alternative procedures; services or materials for the dental condition based on professionally recognized standards of dental practice. However, by following the Pre-certification process both you and your Dentist will know in advance which services are covered and the benefits that are payable. The covered dental expense will be limited to the Allowable Amount for the procedure, service or material which meets professionally recognized standards of quality dental care and is the most cost effective as determined by a contracted Dental Plan Administrator. If you and your Dentist decide on a more costly procedure, service or material than a contracted Dental Plan Administrator determined is payable under the plan, then benefits will be applied to the selected treatment plan up to the benefit maximum for the most cost effective alternative. You will be responsible for any charges in excess of the benefit amount. A contracted Dental Plan Administrator reserves the right to use the services of dental consultants in the Pre- certification review. Example: 🞟 If a crown is placed on a tooth which can be restored by a filling, benefits will be based on the filling; 🞟 If a semi-precision or precision partial denture is inserted, benefits may be based on a conventional clasp partial denture 🞟 If a bridge is placed and the patient has multiple unrestored missing teeth, Benefits will be based on a partial denture. Participating Dentists When you receive covered dental services from a Participating Dentist, you will be responsible for a coinsurance amount as outlined in the section entitled Summary of Benefits. Participating Dentists will file claims on your behalf. Participating Dentists will be paid directly by the plan, and have agreed to accept a contracted Dental Plan Administrator’s payment, plus your payment of any applicable deductible or coinsurance amount, as payment in full for covered services. If the covered Member recovers from a third party the reasonable value of covered services rendered by a Participating Dentist, the Participating Dentist who rendered these services is not required to accept the fees paid by a contracted Dental Plan Administrator as payment in full, but may collect from the covered Member the difference, if any, between the fees paid by a contracted Dental Plan Administrator and the amount collected by the covered Member for these services. Non-Participating Dentists Services received from a Non-Participating Dentist are not covered. When you receive covered services from a Non- Participating Dentist, you will be responsible for paying the Dentist directly for the entire amount billed by the Dentist. Procedure for Filing a Claim Claims for covered dental Services should be submitted on a dental claim form which may be obtained from the contracted Dental Plan Administrator or at xxxxxxxxxxxx.xxx. Have your Dentist complete the form and mail it to the contracted Dental Plan Administrator Service Center shown on the last page of this booklet. A contracted Dental Plan Administrator will provide payment in accordance with the provisions of this Agreement. You will receive an explanation of benefits after the claim has been processed. All claims for reimbursement must be submitted to a contracted Dental Plan Administrator within one (1) year after the month in which the service is rendered. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the cla:im.

Financial Responsibility for Continuity of Care Services. If a Member is entitled to receive Services from a terminated provider under the preceding Continuity of Care provision, the responsibility of the Member to that provider for Services rendered under the Continuity of Care provision shall be no greater than for the same Services rendered by a Participating Dentist in the same geographic area. Pre-certification of Dental Benefits Before any course of treatment expected to cost more than $250 is started, you should obtain Pre-certification of Benefits. Your Dentist should submit the recommended treatment plan and fees together with appropriate diagnostic X-rays to a contracted Dental Plan Administrator. A contracted Dental Plan Administrator will review the dental treatment plan to determine the benefits payable under the plan. The benefit determination for the proposed treatment plan will then be promptly returned to the Dentist. When the treatment is completed, your claim form should be submitted to a contracted Dental Plan Administrator for payment determination. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. The dental plan provides benefits for covered services at the most cost-effective level of care that is consistent with professionally recognized standards of care. If there are two or more professionally recognized procedures for treatment of a dental condition, this plan will in most cases provide benefits based on the most cost-effective procedure. The benefits provided under this plan are based on these considerations but you and your Dentist make the final decision regarding treatment. Failure to obtain Pre-certification of Benefits may result in a denial of benefits. If the Pre-certification process is not followed, a contracted Dental Plan Administrator will still determine payment by taking into account alternative procedures; services or materials for the dental condition based on professionally recognized standards of dental practice. However, by following the Pre-certification process both you and your Dentist will know in advance which services are covered and the benefits that are payable. The covered dental expense will be limited to the Allowable Amount for the procedure, service or material which meets professionally recognized standards of quality dental care and is the most cost effective as determined by a contracted Dental Plan Administrator. If you and your Dentist decide on a more costly procedure, service or material than a contracted Dental Plan Administrator determined is payable under the plan, then benefits will be applied to the selected treatment plan up to the benefit maximum for the most cost effective alternative. You will be responsible for any charges in excess of the benefit amount. A contracted Dental Plan Administrator reserves the right to use the services of dental consultants in the Pre- certification review. Example: 🞟 If a crown is placed on a tooth which can be restored by a filling, benefits will be based on the filling; � � If a semi-precision or precision partial denture is inserted, benefits may be based on a conventional clasp partial denture  🞟 If a bridge is placed and the patient has multiple unrestored missing teeth, Benefits will be based on a partial denture. Participating Dentists When you receive covered dental services from a Participating Dentist, you will be responsible for a coinsurance amount as outlined in the section entitled Summary of Benefits. Participating Dentists will file claims on your behalf. Participating Dentists will be paid directly by the plan, and have agreed to accept a contracted Dental Plan Administrator’s payment, plus your payment of any applicable deductible or coinsurance amount, as payment in full for covered services. If the covered Member recovers from a third party the reasonable value of covered services rendered by a Participating Dentist, the Participating Dentist who rendered these services is not required to accept the fees paid by a contracted Dental Plan Administrator as payment in full, but may collect from the covered Member the difference, if any, between the fees paid by a contracted Dental Plan Administrator and the amount collected by the covered Member for these services. Non-Participating Dentists Services received from a Non-Participating Dentist are not covered. When you receive covered services from a Non- Participating Dentist, you will reimbursed up to a specified maximum amount as outlined in the section entitled Summary of Benefits and Member Coinsurance. You will be be responsible for paying the Dentist directly for the entire amount billed remainder of by the Dent’s billed chargesisYou should discuss this beforehand with your Dentist if he is not a Participating Dentist. Any difference between a contracted Dental Plan Administrator’s or Blue Shield of California’s payment and the Non-Participating Dentist's charges are your responsibility. Members are expected to follow the billing procedures of the dental office. If your receive covered Services from a Non-Participating Dentist, either you or your provider may file a claim using the dental claim form which may be obtained by calling Dental Member Services at: Claims for all Covered California services should be sent to: Blue Shield of California Dental Plan Administrator [P O Box 400 Chico, CA 95927] t. Procedure for Filing a Claim Claims for covered dental Services should be submitted on a dental claim form which may be obtained from the contracted Dental Plan Administrator or at xxxxxxxxxxxx.xxx. Have your Dentist complete the form and mail it to the contracted Dental Plan Administrator Service Center shown on the last page of this booklet. A contracted Dental Plan Administrator will provide payment in accordance with the provisions of this Agreement. You will receive an explanation of benefits after the claim has been processed. All claims for reimbursement must be submitted to a contracted Dental Plan Administrator within one (1) year after the month in which the service is rendered. A contracted Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim.