IMPORTANT TRANSPARENCY IN COVERAGE INFORMATION
The information provided below applies to 2021 Individual On-Exchange plans unless otherwise noted. This information is meant to be a guide and this information does not modify any of the terms of your Subscriber Certificate. For specific information on your plan, please review your specific policy/plan materials (e.g. your Subscriber Certificate).
Balance billing occurs when a participating dentist bills you for charges (other than charges that result from co-payments, coinsurance or deductibles) after we have paid your claim. Participating dentists within our network have agreed to accept our contracted fee as full payment and have agreed not to bill you above their contracted fee. When you see a dentist within our network of dentists, balance billing is not permitted.
If the amount billed by a dentist that is not within the network of dentists is more that the payment amount allowed under your contract, you are responsible for paying the dentist the percentage amount listed in your subscriber certificate, plus the difference between the payment we allow for the service and the payment charged by the dentist. Please understand that a dentist that is outside of the network of dentists is under no obligation to limit the amount charged and you are responsible for the amount charged by the dentist.
If you are enrolled on an EPO policy and you receive emergency care from a dentist outside of the network of dentists because you cannot reasonably access a participating dentist, covered services for the emergency care will be treated as if they were rendered by a dentist in the network of dentists. Specifically, you will not be liable for a greater out-of-pocket expense than if you were seen by a participating dentist.
A participating provider will submit claims to us on your behalf. If you seek services from a dentist outside of our network of dentists, the dentist should submit a claim to us or you will need to submit your own claim for services within twelve (12) months of receiving the service to:
P.O. Box 2906
Milwaukee, WI 53201-2906
To obtain a claim form, please contact member services at 888-278-7310 or click here to download. Please fill out and submit the claim form and any supporting documentation to the address listed above.
A claim is pending when it has been submitted to us and is under process by the claims department.
A grace period of thirty-one (31) days will be granted for the payment of each premium falling due after the first premium, during which grace period the Policy shall continue in force.
If you are receiving advance payments of the premium tax credit under the ACA, and you have previously paid at least one full month’s premium during the benefit year, the grace period is extended to three (3) consecutive months. We may pend claims made during the second and third months of the extended three (3) month grace period. If your premium is not paid by the end of the grace period, coverage will be terminated as of the end of the first month of the grace period and claims pended during the second and third months of the grace period will be denied.
Retroactive Claims Denials
As outlined in your Subscriber Certificate, we will pay for claims submitted for covered services if you are eligible for coverage at the time the services were rendered.
If for any reason your coverage is retroactively terminated, we may retroactively deny your claims. If a retroactive coverage termination occurs, we may retract any payments made to your dentist and the dentist may seek to recoup the payment for the services from you.
You can prevent retroactive denials by paying your premium on time, providing us with the correct information, ensuring you are covered when the services are rendered, and contacting us with any questions you may have about your eligibility.
If you believe you have paid too much for your premium and should receive a refund, please call the member service number on the back of your ID card.
Medical Necessity and Prior Authorization
The Essential Health Benefits requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary. In the case of orthodontia, this means that only orthodontic treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered an Essential Health Benefit. Medically necessary orthodontia was not specifically defined by federal law or regulation and coverage may vary by state. Please refer to your Subscriber Certificate and Schedule of Benefits for a description of covered, medically necessary orthodontia. Please note that medical necessity review turn-around times may vary by state, as follows:
- Florida, Ohio, Pennsylvania, Texas and Georgia Plans
Routine prior authorization requests will be processed within 5 business days of receiving complete information from your dentist, and we will respond to prior authorization requests within 30 calendar days
- Arizona and Illinois Plans
Routine prior authorization requests will be processed within 10 business days of receiving complete information from your dentist, and we will respond to prior authorization requests within 30 calendar days
- Virginia and Tennessee Plans
Routine prior authorization requests will be processed within 2 business days of receiving complete information from your dentist, and we will respond to prior authorization requests within 30 calendar days
- Missouri Plans
Routine prior authorization requests will be processed within 36 hours (including 1 business day) of receiving complete information from your dentist, and we will respond to prior authorization requests within 30 calendar days
- Indiana and Louisiana Plans
Routine prior authorization requests will be processed within 14 calendar days of receiving complete information from your dentist, If we require additional information from your dentist to make a decision, we may extend the timeline an additional 14 calendar days. If the request is urgent or an emergency, we will process the request and notify you of our decision in 72 hours from the time that we receive it.
Failure to follow proper prior authorization procedures may result in claims being denied.
Coordination of Benefits
Coordination of benefits, or COB, is when you are covered under one or more other group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan is responsible for providing benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about Coordination of Benefits can be found in your subscriber certificate and may vary according to state law.
Explanation of Benefits
An Explanation of Benefits (EOB) is a statement that explains which services were paid on your behalf, the amount your plan covered, and the copay that was due and paid at the time of the office visit. EOBs are generally sent within thirty (30) days of our receipt of a claim.
If any part of your claim is denied you will receive an EOB that includes:
- The reason for the denial.
- Notice of your right to request reconsideration of the denial, and an explanation of the grievance procedures.
How to Read an EOB
EOBs have three main sections:
- Claim information is provided at the top and includes the subscriber and patient name, claim number, the dentist’s name and the date the claim was reviewed.
- Coverage information includes a list of services the provider billed for by the Date of Service (DOS) and the American Dental Association Code along with the description of the service, the tooth, surface and quantity and the Member Co-pay that was paid at the time of the office visit.
- Below the totaled amounts is the Service Line Explanation. This section includes any additional information, including reasons for claim denials.
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