Request for Predetermination of Benefits. If the cost estimate of a dental procedure is more than Two Hundred Fifty Dollars ($250) and the treatment is not emergency care, the dentist can determine the treatment needed and submit a treatment plan to DDPOK for predetermination of benefits. This procedure will enable a Subscriber, dependent, or beneficiary and the dentist to know in advance of treatment what services are covered, how much of the cost will be paid by this Plan, and how much of the cost will be the responsibility of the Subscriber, dependent, or beneficiary. The Predetermination of Benefits is only an estimate and not a guarantee of payment. The patient must be eligible for Benefits at the time services are actually rendered, and the procedure must be a Covered Service on the date of service.
Appears in 4 contracts
Samples: Dental Insurance Agreement, Dental Insurance Agreement, Plan Agreement
