Common use of Network Benefits Clause in Contracts

Network Benefits. Benefits - Benefits apply when you choose to obtain Covered Dental Care Services from a Network Dental Provider. Network Benefits are determined based on the contracted fee for each Covered Dental Service. In no event, will you be required to pay a Network Dental Provider an amount for a Covered Dental Service that is greater than the contracted fee. In order for Covered Dental Care Services to be paid, you must obtain all Covered Dental Care Services directly from or through a Network Dental Provider. You must always check the participation status of a provider prior to seeking services. From time to time, the participation status of a provider may change. You can check the participation status by contacting us and/or the provider. We can provide help in referring you to a Network Dental Provider. We will make available to you a Directory of Network Dental Providers. You can also call us at the number stated on your identification (ID) card to determine which providers participate in the Network. Benefits are not available for Dental Care Services that are not provided by a Network Dental Provider. Referral to Out-of-Network Specialist You may request a referral to an out-of-Network Dental Provider who is a non-Physician Specialist if a Covered Person is diagnosed with a condition or disease that requires specialized Dental Services, and: • There is no Network Dental Provider with the professional training and expertise to treat or provide Dental Services for the condition or disease; or • We cannot provide reasonable access to a Network Dental Provider with the professional training and expertise to treat or provide Dental Services for the condition or disease without unreasonable delay or travel. The Covered Person or Dental Provider requesting the referral must contact us to obtain our approval of the referral. The term "non-Physician Specialist" means a health care provider who: • Is not a Physician; • Is licensed or certified under the Maryland Health Occupations Article; and • Is certified or trained to treat or provide Dental Services for a specified condition or disease in a manner that is within the scope of the license or certification of the health care provider.

Network Benefits. Benefits - Benefits apply when you choose to obtain Covered Dental Care Services from a Network Dental Provider. Network Benefits are determined based on the contracted fee for each Covered Dental Service. In no event, will you be required to pay a Network Dental Provider an amount for a Covered Dental Service that is greater than the contracted fee. In order for Covered Dental Care Services to be paid, you must obtain all Covered Dental Care Services directly from or through a Network Dental Provider. You must always check the participation status of a provider prior to seeking services. From time to time, the participation status of a provider may change. You can check the participation status by contacting us and/or the provider. We can provide help in referring you to a Network Dental Provider. We will make available to you a Directory of Network Dental Providers. You can also call us at the number stated on your identification (ID) card to determine which providers participate in the Network. Benefits are not available for Dental Care Services that are not provided by a Network Dental Provider. Referral to Out-of-Network Specialist SAMPLE You may request a referral to an out-of-Network Dental Provider who is a non-Physician Specialist if a Covered Person is diagnosed with a condition or disease that requires specialized Dental Services, and: • There is no Network Dental Provider with the professional training and expertise to treat or provide Dental Services for the condition or disease; or • We cannot provide reasonable access to a Network Dental Provider with the professional training and expertise to treat or provide Dental Services for the condition or disease without unreasonable delay or travel. The Covered Person or Dental Provider requesting the referral must contact us to obtain our approval of the referral. The term "non-Physician Specialist" means a health care provider who: • Is not a Physician; • Is licensed or certified under the Maryland Health Occupations Article; and • Is certified or trained to treat or provide Dental Services for a specified condition or disease in a manner that is within the scope of the license or certification of the health care provider.