Common use of Predetermination of Benefits Clause in Contracts

Predetermination of Benefits. If a course of treatment can reasonably be expected to involve Covered Dental Expenses of $200.00 or more, a description of the procedures to be performed and an estimate of the dentist's charges must be filed with the prepayment agency prior to the commencement of the course of treatment. The prepayment agency will notify the employee and the dentist of the benefits certified as payable based upon such course of treatment. In determining the amount of benefits payable, consideration will be given to alternate procedures, services, or courses of treatment that may be performed for the dental condition concerned in order to accomplish the desired result. The amount included as certified dental expenses will be the appropriate amount as provided in Sections III and IV, determined in accordance with the limitations set forth in Section VI. If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, the prepayment agency reserves the right to make a determination of benefits payable taking into account alternate procedures, services or courses of treatment, based on accepted standards of dental practice. To the extent verification of Covered Dental Expenses cannot reasonably be made by the prepayment agency, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. This predetermination requirement will not apply to courses of treatment under $200.00 or to emergency treatment, routine oral examinations, x rays, prophylaxis and fluoride treatments.

Predetermination of Benefits. If a course of treatment can reasonably be expected to involve Covered Dental Expenses covered dental expenses of $200.00 or more, a description of the procedures to be performed and an estimate of the dentist's charges must be filed with the prepayment agency prior to the commencement of the course of treatment. The prepayment agency will notify the employee and the dentist of the benefits certified as payable based upon such course of treatment. In determining the amount of benefits payable, consideration will be given to alternate procedures, services, or courses of treatment that may be performed for the dental condition concerned in order to accomplish the desired result. The amount included as certified dental expenses will be the appropriate amount as provided in Sections sections III and IV, determined in accordance with the limitations set forth in Section section VI. If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, the prepayment agency reserves the right to make a determination of benefits payable taking into account alternate procedures, services or courses of treatment, based on accepted standards of dental practice. To the extent verification of Covered Dental Expenses covered dental expenses cannot reasonably be made by the prepayment agency, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. This predetermination requirement will not apply to courses of treatment under $200.00 or to emergency treatment, routine oral examinations, x x-rays, prophylaxis and fluoride treatments.

Predetermination of Benefits. If a course of treatment can reasonably be expected to involve Covered Dental Expenses of $200.00 or more, a description of the procedures to be performed and an estimate of the dentist's charges must be filed with the prepayment agency prior to the commencement of the course of treatment. The prepayment agency will notify the employee and the dentist of the benefits certified as payable based upon such course of treatment. In determining the amount of benefits payable, consideration will be given to alternate procedures, services, or courses of treatment that may be performed for the dental condition concerned in order to accomplish the desired result. The amount included as certified dental expenses will be the appropriate amount as provided in Sections III and IV, determined in accordance with the limitations set forth in Section VI. If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, the prepayment agency reserves the right to make a determination of benefits payable taking into account alternate procedures, services or courses of treatment, based on accepted standards of dental practice. To the extent verification of Covered Dental Expenses cannot reasonably be made by the prepayment agency, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. This predetermination requirement will not apply to courses of treatment under $200.00 or to emergency treatment, routine oral examinations, x x-rays, prophylaxis and fluoride treatments.