Non-Participating Dentists. When you receive covered services from a Non- Participating Dentist, you will be reimbursed up to the applicable percentage as specified in the Blue Shield of California Payment Percentage section in the Summary of Benefits. You will be responsible for the remaining percentage amount plus the remainder of the Dentist’s billed charges. You 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. Subscribers are expected to follow the billing procedures of the dental office. If your receive covered Services from a Non-Par- ticipating Dentist, either you or your provider may file a claim using the dental claim form which may be obtained by calling Dental Cus- tomer Services at: 0-000-000-0000 Claims for all Services rendered by Non-Partici- pating Dentists, should be sent to: Blue Shield of California P O Box 272590 Chico, CA95927-2590 Calendar Year Deductible per person
Non-Participating Dentists. When you receive covered services from a Non- Participating Dentist, you will be reimbursed up to the applicable percentage as specified in the Blue Shield of California Payment Percentage section in the Summary of Benefits. You will be responsible for the remaining percentage amount plus the remainder of the Dentist’s billed charges. You 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. Subscribers are expected to follow the billing procedures of the dental office. If your receive covered Services from a Non-Par- ticipating Dentist, either you or your provider may file a claim using the dental claim form which may be obtained by calling Dental Cus- tomer Services at: 0-000-000-0000 Claims for all Services rendered by Non-Partici- pating Dentists, should be sent to: Blue Shield of California P O Box 272590 Chico, CA95927-2590 Calendar Year Deductible per person Except as noted, the Calendar Year Deductible applies to all covered Services and supplies furnished by Participating and Non-Participating Dentists 1. It is the amount that you must pay out of pocket before benefits will be provided for covered Services. This Deductible applies sepa- rately to each covered Person each Calendar Year. 1 The Calendar Year Deductible does not apply to those dental Services considered by Blue Shield of California to be Diagnostic or Preven- tive. Please see the Summary of Benefits for ad- ditional information. Maximum Blue Shield of California Calen- dar Year Payment The maximum payment each Calendar Year for covered Services by any combination of Partici- pating and Non-Participating Dentists is shown in the Summary of Benefits. No benefits in ex- cess of this amount will be provided to or on be- half of any Person. Procedures for Filing a Claim Claims for covered dental services should be sub- mitted on a dental claim form which may be ob- tained from a contracted Dental Plan Administrator, or any Blue Shield of California Office. Have your Dentist complete the form and mail it to a contracted Dental Plan Administrator. A contracted Dental Plan Administrator will pro- vide payments in accordance with the provision of the contract. You will receive an explanation of benefits after the claim has been processed. All claims for reimbursement must be submitted to a co...
Non-Participating Dentists. Except as otherwise required by law, a reasonable amount as determined by Anthem BCBS, after consideration of such industry cost, reimbursement and utilization data and indices, as Anthem BCBS deems appropriate in its discretion, which is assigned as reimbursement for Covered Services provided to a Covered Person or an amount negotiated with a Non-Participating Dentist for Covered Services provided to a Covered Person. The amount Anthem BCBS will pay for Covered Services on behalf of Employer will be the Maximum Allowable Amount or the billed charges, whichever is lower. It is the Covered Person’s obligation to pay Cost Shares as a component of this Maximum Allowable Amount and amounts in excess of the Maximum Allowable Amount. Please note that the Maximum Allowable Amount may be greater or less than the Participating Dentist’s or Non-Participating Dentist’s billed charges for the Covered Service. Anthem BCBS shall have discretionary authority to establish, as it deems appropriate, the Maximum Allowable Amount under the Benefit Program. Medically Necessary Care (Medically Necessary or Medical Necessity): The term Medically Necessary Care (Medically Necessary or Medical Necessity) means services, supplies or treatment rendered by a Provider which, in the judgment of Anthem BCBS, is or are:
Non-Participating Dentists. Benefits are paid at the Out of Network benefit level. Members may be held liable for the difference between the dentist’s billed charge and the non‐participating allowable. Advantages . Freedom to choose your dentist ODS has PPO contracts with over 700 dentists in Oregon and approximately 74,000 dentists nationwide through our affiliation with the national Delta Dental network. We are unique in that we also offer a safety net through our Premier network of dentists, having over 2,000 contracted licensed dentists in Oregon. As the Delta Dental Plan of Oregon, we offer access to over 131,000 Premier dentists nationwide. . Professional Arrangements ODS and other Delta Dental member companies have specific negotiated fees with our participating dentists to ensure that actual charges made by the dentist do not exceed his or her accepted or contracted fees on file. We believe that the underlying unique feature inherent to all ODS programs is every participating dentist becomes a party to cost control as well as the quality of care. Participating dentists will update your records with your new information and will submit claims to ODS for you. . myModa is a customized member website with current, accurate and easy to understand information about your plan. Log onto xxx.xxxxxxxxxx.xxx/xxxxxxx to access myModa. Dependent Eligibility . Dependents are lawful spouse, state registered same gender domestic partners and eligible children to age 26, including children an employee is required to enroll due to a court or administrative order. This is a benefit summary only. For a more detailed description of benefits, refer to your member handbook. Visit our website at xxx.xxxxxxxxxx.xxx Moda‐DenPPO‐BPA3X25_PF 7/1/2012(Rev.02/25/14) JK Dental products provided by Oregon Dental Service Summary of Dental Benefits All plans offered and underwritten by Xxxxxx Foundation Health Plan of the Northwest. 000 XX Xxxxxxxxx Xx., Xxxxx 000, Xxxxxxxx, XX 00000 Membership Services: 0-000-000-0000 Oregon LHBP 7/1/2018 - 6/30/2019 City of Xxxxxxx, A Municipal Corporation of The State of Oregon dba City of Xxxxxxx Group Number: 18120-004 Benefit Maximum per Member, per Calendar Year None You pay Dental Office Visit Charge – Applies to all visits $10 Deductible (Per Calendar Year For one Member $0 For an entire Family $0 Preventive and Diagnostic Services Oral exam $0 X-rays $0 Teeth cleaning $0 Fluoride $0 Basic Restoration Services Routine fillings $0 Plastic and steel crowns $0 Simple ext...
Non-Participating Dentists. If you visit a non-participating dentist, you may be required to submit your own claim and pay for services at the time they are provided. Claim forms are available by visiting xxxxxxx.xxx or by calling Northeast Delta Dental. Payment will be made to you, the Subscriber, unless the state in which the services are rendered requires that assignment of benefits be honored and Northeast Delta Dental receives written notice of such assignment. Payment for treatment performed by a non-participating dentist will be limited to the lesser of the dentist’s actual submitted charge or Delta Dental’s allowance for non-participating dentists in the geographic area in which services are provided. It is your responsibility to make full payment to the dentist. Predetermination of Benefits Northeast Delta Dental recommends that you ask your dentist to submit a pre-treatment estimate for any dental work involving costly or extensive treatment plans. Predeterminations helps avoid any potential confusion and enable us to help you estimate any out-of-pocket expenses you may incur. Coordination of Benefits When an individual covered under this plan has additional group coverage, the Coordination of Benefits (COB) provision described in your Dental Plan Description booklet will determine the sequence and extent of payment. If you have any questions about COB, please contact our Customer Service Department at 0-000-000-0000. Identification Cards Two identification cards will be produced and distributed shortly after your initial enrollment. Both cards are issued in your name but can be used by any family member covered under your plan. Any future cards will be issued electronically via our Benefit Lookup site accessible through xxxxxxx.xxx. You can also use our smartphone app and enjoy access to dentist search, claims and coverage, and your ID card. Simply scan the QR code to the right. Health through Oral Wellness® (HOW®) A healthy mouth is part of a healthy life, and Northeast Delta Dental’s innovative Health through Oral Wellness program (HOW) works with your dental benefits to help you achieve and maintain better oral wellness. HOW is all about YOU because it’s based on your specific oral health risk and needs. Best of all, it’s secure and confidential. Here’s how to get started:
