Notification for Enrollees Clause Samples

Notification for Enrollees. When a claim for Services is approved for payment, Delta Dental shall notify the Enrollee of the Dentist’s charge, Delta Dental’s calculation of the PPO Allowed Amount or Delta Dental’s calculation of the Allowed Amount, and amounts for which the Enrollee is obligated to pay under this Contract. If the Services are provided by a PPO Dentist, the Enrollee’s obligation to pay the PPO Dentist is limited to any applicable deductible and co-payment, and any portion of the PPO Allowed Amount which exceeds applicable program maximums. If the Services are provided by a Participating Dentist who is not a PPO Dentist, the Enrollee’s obligation to pay that Participating Dentist is limited to any applicable deductible, co-payment, and any portion of the Allowed Amount which exceeds applicable program maximums. If the Services are provided by a Non-Participating Dentist, the Enrollee’s payment obligation to the Non-Participating Dentist is not limited by this Contract. DELTA DENTAL OF NEW YORK, INC. (1) Denial of payment based upon lack of coverage of benefit under the Contract or Enrollee’s eligibility status i.e., claim benefit determinations that are not considered Utilization Review under Article 49 of the New York Insurance Law. If a post-service claim1 is denied in whole or in part, Delta Dental shall notify the Enrollee and the attending dentist of the denial in writing within thirty (30) days after the claim is filed, unless special circumstances require an extension of time, not exceeding fifteen (15) days, for processing. If there is an extension, the Enrollee and the attending dentist shall be notified of the extension and the reason for the extension within the original thirty (30) day period. If an extension is necessary because either the Enrollee or the attending dentist did not submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information. The Enrollee or the attending dentist shall be afforded at least forty-five (45) days from receipt of the notice within which to provide the specific information. The extension period (15 days) – within which a decision must be made by Delta Dental – will begin to run from the date on which the Enrollee’s response is received by the plan (without regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days). The notice of denial shall ex...