How The Plan Administrator Determines What It Pays For Covered Services. The Plan Administrator bases its payment of Benefits for a Plan Participant’s Covered Services on an amount known as the “Allowable Charge.” The Allowable Charge is determined according to the Methodology for Establishing the Dental Fee Schedule. If the amount that is billed for Covered Services by the Plan Participant’s Provider is less than the amount that the Plan Administrator has set for the Covered Service, the billed amount is the Allowable Charge and the Plan Administrator’s payment will be based on the billed amount. When a Plan Participant receives a dental diagnosis from a Participating Provider for a Covered Service under this Benefit Plan, the Plan Participant may choose to have the covered Benefit as designated by this dental Benefit Plan; or an alternate type, form, or quality of dental service which is of equal or greater price, provided the Plan Participant approves the alternate service in advance and in writing. In that case, the Plan Administrator will pay Contract Benefits as if the covered service was actually rendered, and the Plan Participant must pay the difference between the covered Benefit and the amount of the chosen alternative service or procedure.
How The Plan Administrator Determines What It Pays For Covered Services. The Plan Administrator bases its payment of Benefits for a Plan Participant’s Covered Services on an amount known as the “Allowable Charge.” The Allowable Charge is determined according to the Methodology for Establishing the Dental Fee Schedule. If the amount that is billed for Covered Services by the Plan Participant’s Provider is less than the amount that the Plan Administrator has set for the Covered Service, the billed amount is the Allowable Charge and the Plan Administrator’s payment will be based on the billed amount. Louisiana law allows a dental patient to choose any type, form or quality of dental service or procedure, for which dental coverage is not available, as long as the patient approves in advance and in writing the charges for which he will be responsible to the Provider. When a Plan Participant receives a dental diagnosis from a Participating Provider for a Covered Service under this Benefit Plan, the Plan Participant may choose to have the covered Benefit as designated by this dental Benefit Plan; or an alternate type, form, or quality of dental service which is of equal or greater price, provided the Plan Participant approves the alternate service in advance and in writing. In that case, the Plan Administrator will pay Contract Benefits as if the covered service was actually rendered, and the Plan Participant must pay the difference between the covered Benefit and the amount of the chosen alternative service or procedure.
