Att C1 - Certificate of Coverage Dentacare DHMO Anthem.pdf

You’ve made a good decision in choosing Dentacare HMO

39801B (8/10)

Dunn County Employees

For more information, visit our web site at anthem.com

01/01/2019 00128279 FWI13-MB GRGR

DNGW0094

Dental benefits underwritten by Compcare Health Services Insurance Corporation, an independent licensee of the Blue Cross and Blue Shield Association

Registered marks Blue Cross and Blue Shield Association.

Table of

Contents 1 Dental Certificate D-1

Dental benefits underwritten by Compcare Health Services Insurance Corporation

2 HIPAA Notice of Privacy Practices M-1

Underwritten by Compcare Health Services Insurance Corporation

Your Dental

Certificate

Dental benefits underwritten by Compcare Health Services Insurance Corporation

Dental Certificate of Coverage

WI Dentacare 100

BENEFIT HANDBOOK

We settle claims based upon varying methodologies, which may be less than the provider’s billed charge.

Please see page D-28 of this Booklet for a more detailed explanation.

IMPORTANT NOTICE REGARDING STATEMENTS IN THE ENROLLMENT FORM

FOR YOUR INSURANCE

Please review the copy of the enrollment form you completed when applying for coverage. Omissions or misstatements in the enrollment form could cause an otherwise valid claim to be denied. Carefully check the enrollment form and write to Us within ten (10) days if any information in the form is incorrect or if any information is missing.

ANTHEM BLUE CROSS AND BLUE SHIELD

P.O. Box 659444

San Antonio, TX 78265-9444 1-866-589-0582

Please Direct Correspondence, Claims & Grievances To:

ANTHEM BLUE CROSS AND BLUE SHIELD

P.O. Box 659471 San Antonio, TX 78265-9471

COMPCARE HEALTH SERVICES INSURANCE CORPORATION ("COMPCARE")

dba ANTHEM BLUE CROSS AND BLUE SHIELD

N17 W24340 Riverwood Drive Waukesha, WI 53188

39801B (8/10)

Contents D-3

Contents 1 GENERAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4

IDENTIFICATION (ID) CARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4 CUSTOMER SERVICE INQUIRIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4 SELECTING YOUR DENTIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4 MAKING AN APPOINTMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4 COVERAGE PROVIDED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4

2 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-5 3 ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-7

DEPENDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-7 COVERAGE OF DEPENDENT STUDENTS ON MEDICAL LEAVE . . . . . . . . . . . . . . . . . D-7 APPLICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-8 BADGERCARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-8 EFFECTIVE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-8 CESSATION OF ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-9 INDIVIDUAL REINSTATEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-9 COURT-ORDERED COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-9

4 DENTAL UTILIZATION REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-10 5 COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-11

WHILE UNDER THE CARE OF GROUP DENTISTS . . . . . . . . . . . . . . . . . . . . . . . . . D-11

WHILE UNDER THE CARE AND TREATMENT OF DENTISTS OTHER THAN GROUP DENTISTSD-13

6 GENERAL EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-14

7 HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED . . . . . . . . . . . . . . . . D-15

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-15 Provider Network Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-16 Network Dentist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-16 Non-Network Dentist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-16 Member Cost Share . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-17

8 COORDINATION OF THE CONTRACT’S BENEFITS WITH OTHER BENEFITS . . . . D-17

APPLICABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-17 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-18 ORDER OF BENEFIT DETERMINATION RULES . . . . . . . . . . . . . . . . . . . . . . . . . . . D-18 EFFECT ON THE BENEFITS OF THIS PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-20 RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION . . . . . . . . . . . . . . . . . . D-20 FACILITY OF PAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-20 RIGHT OF RECOVERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-20

9 DISENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-20 10 TERMINATION AND CONTINUATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-21

TERMINATION OF INDIVIDUAL COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . D-21 CONTINUATION OF COVERAGE UNDER COBRA . . . . . . . . . . . . . . . . . . . . . . . . . D-21

11 GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-25

Dental Certificate

D-4 GENERAL INFORMATION

1 GENERAL INFORMATION

IDENTIFICATION (ID) CARDS

You will receive a DENTACARE ID card. It ends most red tape and claim procedures. Show your card to your dentist when requesting services.

CUSTOMER SERVICE INQUIRIES

If you have questions regarding your coverage, please call the appropriate Customer Service location listed below.

ANTHEM BLUE CROSS AND BLUE SHIELD

P.O. Box 659444

San Antonio, TX 78265-9444 1-866-589-0582

SELECTING YOUR DENTIST

Regardless of any previous dental relationship You may have had, You have now elected to obtain dental care through the Dentacare Center and its staff. A professional staff of Dentists, hygienists, and assistants will take care of Your dental needs at Your Center. With the help of Your Dentacare Center staff, You will choose a personal Dentist for Your dental care. After a preliminary examination, x-rays and diagnosis, You should continue to see the same Dentist for Your dental care. Or, if You wish, You may choose another Dentist from those participating at Your Center. Your selection may be accepted or rejected depending on whether Your chosen Dentist is available for new patients and/or is a participating Dentist. If at any time you waive your right to make a selection, We may transfer Your care to a Dentacare Dentist or Dental Center of our choosing.

Under their contract with Us, the dental professionals and dental facilities may receive financial incentives to provide covered services in the most cost-efficient manner consistent with sound dental practice and without compromising the patient’s health.

MAKING AN APPOINTMENT

DENTACARE Services are offered at Your convenience, whenever possible. When You wish to see Your DENTACARE Dentist, call Your center for an appointment. It is important always to call first for an appointment in order to get more efficient service.

If You are unable to keep an appointment, please call Your Dentist’s office at least 24 hours in advance or as soon as possible before the scheduled appointment time. Failure to do so may result in a charge to You for the missed appointment. Should You need immediate advice or emergency care, a DENTACARE Dentist is on call 24 hours a day.

COVERAGE PROVIDED

This booklet is not the Contract. If there is a conflict between the Contract and this booklet, the Contract controls. Subject to the limitations, exclusions and conditions of the Contract, You are entitled to the Dental Services and Emergency Services described in this booklet.

DEFINITIONS D-5

2 DEFINITIONS

As used in this booklet, the following terms are defined as:

BENEFITS means Dental Service and Emergency Service performed, to the extent specified herein.

CO-INSURANCE means a portion of the Maximum Allowed Amount for Dental Services for which You are responsible. Your Coinsurance will not be reduced by refunds, rebates, or any other form of negotiated post-payment adjustments.

CONTRACT - the written agreement We have with the Group. The contract defines the benefits, terms and conditions of coverage.

DENTAL GROUP - the Dental Center you are enrolled in as shown on Your identification card.

DENTAL SERVICE - those professional services of Dentists, and the professional and para-dental personnel engaged by the Dental Group. This includes diagnostic, therapeutic and preventive services. Dental Services must be documented in provider records.

DENTIST - a licensed Doctor of Dental Surgery, a licensed Doctor of Medical Dentistry, or equivalent, as recognized by the American Dental Association. This includes any other professional practitioner authorized by law to practice dentistry at the time and place Dental Services are performed.

DEPENDENT - a Participant other than You.

Dependent is described in Dependent Eligibility.

EFFECTIVE DATE - the date on which a Participant’s coverage becomes effective.

EMERGENCY SERVICE - Dental Service which is needed unexpectedly and immediately due to accidental injury or emergency illness while the Participant is outside the Service Area. It does not include elective care or care which the Participant could reasonably have foreseen before leaving the area.

EMPLOYEE - means a member of the Group who:

1. Meets the Group’s eligibility requirements for fringe benefits;

2. Meets the Contract’s eligibility requirements;

3. Has applied and been accepted by Us for coverage under this Contract; and

4. Has caused premium payment to be made on his behalf.

EXPEDITED GRIEVANCE - means a Grievance which requires immediate consideration and involves any of the following circumstances:

1. Serious jeopardy to the life or health of the Member or the ability of the Member to regain maximum function;

2. A situation where, in the opinion of a Dentist with knowledge of the Member’s condition, the Member would be subjected to severe pain that cannot be adequately managed without the service or treatment that is the subject of the grievance.

3. It is determined by a Dentist with knowledge of the Member’s dental condition that an Expedited Grievance exists.

EXPERIMENTAL/INVESTIGATIONAL -

means procedures not yet recognized by the American Dental Association as indicated with a specific procedure code designation, or procedures which are not widely accepted as proven and effective procedures within the organized dental community.

Decisions made to deny or limit dental treatment based on an Experimental/Investigational basis are made by a licensed Dentist or any other professional practitioner licensed to practice dentistry. In the event You disagree with this or any decision you have the right to file a written Grievance. You will find details on how to do this in the General Provisions section of this booklet. You may also contact Our customer service number on your ID card.

D-6 DEFINITIONS

A request for a pre-treatment determination may be submitted in writing to Us. If prior written approval for a treatment, or service is provided, benefits will be paid if the Member’s coverage is in force and if the approval has not expired at the time such treatment, or service is provided.

GRIEVANCE - means a written complaint that You, or someone on Your behalf, files with Us. The Grievance may involve Your dissatisfaction with Our administration or claims practices, the provision of services, denial of services, or limitations based on Experimental / Investigational treatment.

GROUP - the employer, organization, or Association through which You have this coverage.

GROUP DENTIST - A Dentist associated with or engaged by the Dental Group.

LABORATORY CHARGES - Charges for an indirect restoration, or a prosthetic device. It includes charges for repairs to those items.

MAXIMUM ALLOWED AMOUNT - the maximum amount of reimbursement We will allow for Dental Services under the plan, as outlined in the “How Maximum Allowed Amount is Determined” section of this Booklet.

MEDICALLY NECESSARY (MEDICAL

NECESSITY) - Medically Necessary procedures, services, or treatments are those that are:

1. Appropriate and necessary for the symptoms, diagnosis, or treatment of the dental condition;

2. Customarily provided for the prevention, diagnosis, or direct care and treatment of the dental condition;

3. Within standards of good dental practice within the organized dental community;

4. Not primarily for your convenience, or the convenience of your provider or another provider; and

5. Based on prevailing dental practices, the least expensive covered service suitable for your dental condition that will produce a professionally satisfactory result.

OPEN ENROLLMENT PERIOD - an Enrollment Period when any eligible Employee or Dependent of the Group may apply for this coverage and existing Participants can change Dental Groups.

PARTICIPANT - means the Employee or any of his Dependents whom the Employee and Group have certified to Us as eligible for benefits hereunder and for whom the appropriate premiums have been paid.

QUALIFYING EVENT - Qualifying Events include the following:

1. Marriage or divorce.

2. Death of a spouse or child.

3. Birth or adoption of a child.

4. Termination or commencement of employment of Employee’s spouse.

5. Change in employment status of either the eligible group Employee or his spouse from full-time to part-time or vice-versa.

6. An unpaid leave of absence (does not include medical leave of absence) by either the eligible group Employee or his spouse.

7. A significant change in the benefit coverage or premium contribution of the eligible group Employee or his spouse attributable to the spouse’s employment.

SERVICE AREA - the area within fifty (50) miles of the Dental Group location.

WE, US (OUR) - COMPCARE HEALTH

SERVICES INSURANCE CORPORATION dba Anthem Blue Cross and Blue Shield, which provides benefits to Members for the Covered Services described in this Booklet

YOU (YOUR) - an eligible person affiliated with the Group, who has enrolled for coverage under the Contract. In the description of Dental Services, "You (Your)" includes your Dependent Participants.

ELIGIBILITY D-7

3 ELIGIBILITY

Unless We have approved different eligibility terms for Your Group, to be eligible, you must: (1) actively perform the duties of your principal occupation; (2) satisfy any probationary period that applies to you; and (3) be eligible for all the fringe benefits which apply to the class of Employees to which you belong.

DEPENDENTS

Dependent Coverage covers only those dependents which you listed on your individual application for coverage. It is important that you accurately and promptly report all your dependents to Us. You should also report to your Group any changes such as births, or additions of step-children within thirty-one (31) days of the event or adoptions within sixty (60) days of the event. Your Group will then notify Us of the changes.

If you have Dependent Coverage, your spouse and dependent children are entitled to the same benefits as you. Your spouse is the person to whom you are lawfully married. Your dependent children are the lawful children of you and/or your spouse. Dependent children are covered from birth through the calendar month they become 26 years old.

If one of your unmarried children is totally and permanently disabled before the end of the calendar year the child reaches the limiting age, and dependent on you for support and maintenance within the meaning of the Internal Revenue Code of the United States, your Plan will continue providing coverage to the child for as long as the child remains disabled and you remain a Participant of the plan. Totally and permanently disabled means he or she is not capable of self-sustaining employment due to mental retardation or physical handicap. You must claim disability status within thirty-one (31) days of the end of that calendar year. We may require proof of disability as often as necessary.

You may also continue coverage if your unmarried child is called to active duty in the

National Guard or in a reserve component of the United States armed forces prior to age 27 and is currently a full-time student, regardless of age.

The Dependent child cannot be eligible for coverage under his/her employer’s group health plan unless the premium for that coverage is greater than the premium charged for a Dependent under this Booklet. Coverage will end when the child ceases to be a full-time student, marries, or becomes eligible for a group health plan for which the premium is less than the premium charged a Dependent under this Booklet. We may require the Subscriber to submit proof of continued eligibility for any enrolled child. Your failure to provide this information could result in termination of a child’s coverage.

If your spouse or dependent children lose their eligibility for this plan, they may apply for continuation coverage.

COVERAGE OF DEPENDENT STUDENTS

ON MEDICAL LEAVE

The information below applies to Dependent students who were called to active duty in the National Guard or in a reserve component of the United States armed forces prior to age 27 and have now returned to school on a full-time basis.

If, while covered under this Booklet, a Dependent student needs to reduce his/her course load or leave school due to a Medically Necessary leave of absence, the Dependent student may be eligible to continue coverage under this Booklet.

We may require documentation of the Medical Necessity of the leave of absence from the Dependent’s attending Physician. The date on which the Dependent ceases to be a full-time student due to the Medically Necessary leave of absence shall be the date on which the continuation of coverage begins.

Coverage will continue until any of the following occurs:

1) We are advised that the Dependent does not intend to return to school full time.

D-8 ELIGIBILITY

2) The Dependent becomes employed full time.

3) The Dependent obtains other health care coverage.

4) The Dependent marries and is eligible for coverage under his or her spouse’s health care coverage.

5) Coverage of the Member through whom the person has Dependent coverage under this Booklet is discontinued or not renewed.

6) One year has elapsed since the Dependent’s continuation of coverage began and the Dependent has not returned to school full time.

APPLICATION

You can apply for coverage at the following times:

1. Within thirty-one (31) days of initial eligibility, or

2. Within thirty-one (31) days of Open Enrollment, or

3. Within thirty-one (31) days of a Qualifying Event.

4. Within 60 days after Medicaid coverage ends.

If you fail to apply within the above stated timeframes, coverage hereunder shall not be available until the next Open Enrollment Period.

BADGERCARE

If the Wisconsin Department of Health and Family Services agrees to purchase coverage under this Booklet for you in lieu of enrolling you in the Medical Assistance Program (under s. 49.472, Wis.

Stat.), Badger Care (under s. 49.665, Wis. Stat.), or BadgerCare Plus (under s. 49.471, Wis. Stat.), you will have 60 days from the date of that determination to apply for this coverage. If we receive your completed application within 60 days, We will enroll you on the first of the month following Our receipt of the application.

EFFECTIVE DATE

Your effective date follows both your completion of any probationary period and Our approval of your application. In no event shall your Effective Date be prior to your completion of the probationary period, if any.

If you apply for your coverage and your dependent’s coverage at the same time, you and your dependent will have the same effective date.

A dependent’s effective date cannot be before your effective date.

If you marry after your coverage is effective, you should apply for Dependent Coverage within thirty-one (31) days of your marriage. If you do, your Dependent Coverage becomes effective on the marriage date.

Coverage for a newborn child begins on the date of birth. If additional payment is required for the newborn, it must be paid within sixty (60) days of the birth; if the payment is not paid within that time, coverage for the newborn ends sixty (60) days after birth. Within one year of the birth, you may reinstate the newborn’s coverage by paying all past due premiums plus interest at the rate of five and one-half percent (5 1

2%) per year.

If you have Dependent Coverage and (1) you adopt a child, or (2) you have a child placed with you for adoption, or (3) you are named the legal guardian for a child, the effective date of coverage for the child is the earlier of:

1. the date of the final court order granting adoption; or

2. the date the child is placed with you or your dependent for adoption.

You are required to notify Us of this and pay the additional premium, if any, within sixty (60) days of the adoption, placement, or appointment.

In all other circumstances, if you apply for Dependent Coverage after your Effective Date, your Dependents shall not be entitled to benefits unless your application for a family-type

ELIGIBILITY D-9

membership has been accepted and Dependent Coverage is in effect. In the event you do not apply for Dependent’s coverage with thirty-one

(31) days after such Dependents first become eligible for coverage, coverage hereunder shall not be available until the next Open Enrollment Period.

You are not covered by your plan until your Effective Date. We will notify you of your Effective Date when sending your Identification Card.

Unless you or your dependent are totally disabled:

You must be actively at work on the Effective Date, if not the Effective Date is the day you return to active work. A day of vacation or holiday is considered active work for purposes of the Effective Date if you are capable of active work on this date.

CESSATION OF ELIGIBILITY

Except as provided herein, your eligibility for benefits under this Contract ceases on the last day of the month in which you no longer meets the eligibility requirements set forth above.

INDIVIDUAL REINSTATEMENTS

If coverage ends because Your employment terminates, Your coverage may be reinstated on Your return to full-time employment. If You return within ninety (90) days of the termination date, coverage is effective on the date of return.

The benefits We reinstate are the benefits that would have been available had You been continuously insured. You must pay any required premium.

If You return to full-time employment more than ninety (90) days after Your termination date, We consider You a new Employee.

If you return to full-time employment upon the completion of an FMLA leave period and you elect to have coverage reinstated or the Group requires your coverage be reinstated, coverage will be reinstated on the date you return from FMLA leave. The benefits We reinstate are the benefits that you and your Dependents would have received if coverage had been continuous.

Following a military leave, if you return or request re-employment within the statutory period, coverage will be reinstated on the date you return. If you had converted your coverage, your conversion policy ends on the day We reinstate this coverage.

COURT-ORDERED COVERAGE

If a court orders a Participant to provide coverage for dental expenses for a child of the Participant and the Participant is eligible for Family Coverage under this Contract, We:

1. Provide Family Coverage under the Contract for the Participant child, if eligible for coverage, without regard to any enrollment period restrictions that may apply under the Contract;

2. Provide Family Coverage under the Contract for the Participant’s child, if eligible for coverage, upon application by the Participant, the child’s other parent, or the Department of Health and Family Services or the county designee under s. 59.07 (97); and

3. After the child is covered under the Contract, and as long as the Participant is eligible for Family Coverage under the Contract, continue to provide coverage for the child unless We receive satisfactory written evidence that the court order is no longer in effect or that the child has coverage under another group policy or individual policy that provides comparable dental coverage.

If We provide coverage under a Contract for a child of a Participant who is not the custodial parent of the child, We shall do all of the following:

1. Provide to the custodial parent of the child information related to the child’s enrollment;

D-10 DENTAL UTILIZATION REVIEW

2. Permit the custodial parent of the child, a dental provider that provides services to the child, or the Department of Health and Family Services to submit claims for Benefits without the approval of the parent who is the Participant; and

3. Pay claims directly to the dental provider, the custodial parent of the child, or the Department of Health and Family Services as appropriate.

4 DENTAL UTILIZATION REVIEW

Dental utilization review is a process designed to promote the delivery of cost-effective dental care by encouraging the use of clinically recognized and proven procedures. Dental utilization review is included in Your dental benefits to encourage You to utilize Your dental benefits in a cost-effective and clinically recognized manner.

Your right to benefits for Dental Services provided under this plan is subject to certain policies, guidelines and limitations, including, but not limited to, Our coverage guidelines, dental policy and utilization review features.

Dental utilization review is accomplished through pre-treatment review and retrospective review. Our dental coverage guidelines for pre-treatment review and retrospective review are intended to reflect the standards of care for dental practice and state-specific regulations. The purpose of dental coverage guidelines is to assist in the interpretation of Medical Necessity. In order to be covered expenses or services under this plan, expenses must meet the Medically Necessary requirements.

Pre-Treatment Review

You may have a pre-treatment review done before you receive benefits. Pre-treatment review is not a prior authorization for services but is a system that allows You and Your Dentist to know, in advance, what the estimated benefits payable would be under this plan for a proposed course of treatment. The actual benefits you receive under the plan will be determined once a claim for services has been received and may vary from the estimated benefits based upon the actual services received as well as the benefit coverage in effect on the date(s) of services.

Under pre-treatment review, Your Dentist prepares a request for a pre-treatment benefit estimation form, and submits this form to us before any treatment begins. The pre-treatment benefit estimation form should: (a) list the recommended dental services; and (b) show the charge for each dental service. We will review this request and send a copy of Our estimated benefits to You and Your Dentist. We may request supporting pre-operative x-rays or other diagnostic records in connection with the pre-treatment review. A pre-treatment review is recommended if the proposed course of treatment is expected to involve charges of $350 or more.

If the course of treatment is not reviewed before treatment is received, it will be reviewed when the claim is submitted to us for payment.

Retrospective Review

Retrospective review means a Medical Necessity review that is conducted after dental care services have been provided. A claim review includes, but is not limited to, an evaluation of reimbursement levels, accuracy of documentation, accuracy of coding and adjudication of payment.

We provide a toll-free telephone number available during normal business hours to assist You or Your Dentist in obtaining information with respect to Our utilization review process.

This same number may be utilized after business hours to leave a message which will be responded to within two business days in non-emergent situations.

If You disagree with a utilization review decision and wish to file a grievance, or appeal a decision previously made You will find details on how to do this in the General Provisions section

COVERED SERVICES D-11

of this booklet. You may also contact Our customer service number on your ID card.

The utilization review process is governed by laws and regulations, and may be modified from time to time by Us as those laws and regulations may require. A more detailed description of the decision making timeframes are set forth in Our utilization review guide. This guide is available by calling customer service at 800-627-0004.

5 COVERED SERVICES

You are entitled to the Dental Services described in this booklet. The Dental Services must begin on or after Your Effective Date, be Medically Necessary, be furnished according to a Dentist’s order, and not be performed primarily for cosmetic or esthetic purposes. Benefits are subject to the terms and conditions of the Contract.

Certain Dental Services are subject to Co-insurance which are specified in this Article.

We calculate Co-insurance based upon Our Maximum Allowed Amount.

WHILE UNDER THE CARE OF GROUP

DENTISTS

A. Diagnostic

1. These dental x-rays: intraoral complete series and periapical films, intraoral occlusal films, bite-wing x-rays, panoramic films, and cephalometric films.

2. Routine oral examinations and Adult or Pediatric Prophylaxis.

a. Adult Prophylaxis means the scaling and cleaning of teeth of Participants thirteen (13) years of age and older.

b. Pediatric Prophylaxis means the scaling and cleaning of teeth of Dependents twelve (12) years of age and under.

Periodontal scaling and root planing is a separate procedure from prophylaxis.

Please refer to the booklet section describing periodontal benefits.

3. Pulp vitality tests.

4. Diagnostic casts and photographs for orthodontic purposes only.

B. Preventive

1. Topical Fluoride Treatment.

2. Oral hygiene, plaque control, and dietary instruction.

3. Initial placement of sealants on posterior permanent teeth within two

(2) years of their eruption. Replacement of sealants is covered only if three (3) years have elapsed since the last placement.

4. Space maintainers that replace prematurely lost primary teeth.

C. Ancillary

1. Intravenous sedation when Medically Necessary. If intravenous sedation is needed because of a medical condition, Your Group Dentist will require a doctor’s statement of Medical Necessity.

We cover intravenous sedation needed because of mental retardation, but not because of patient anxiety.

2. Emergency palliative treatment (relief of pain).

3. Emergency denture repairs and adjustments. You pay any Laboratory Charges.

4. Analgesia (e.g. nitrous oxide-oxygen sedation).

D-12 COVERED SERVICES

D. Restorative

1. Direct Restorations (Fillings) Amalgam, silicate, resin, acrylic, synthetic porcelain, and composite filling restorations of diseased or broken teeth.

2. Indirect Restorations (Cast Restorations).

Inlays, onlays or crowns to restore diseased or broken teeth, if the tooth, as a result of extensive caries or fracture, cannot be restored by direct restoration.

Except for temporary or stainless steel crowns, replacement of crowns is covered only if at least five (5) years have elapsed since the insertion of the existing crown.

You pay any Laboratory Charges at the time of service.

Metal, Baked Porcelain Restorations, Inlays, Crowns, and Jackets: If Your tooth can be restored with amalgam, silicate, resin, acrylic, synthetic porcelain, composite or plastic, these materials will be used. This decision is made by Your Group Dentist.

Posterior Restoration: Benefits are limited to the procedures that are Medically Necessary to achieve restoration. This means that if an amalgam restoration would give a satisfactory result, but You and Your Group Dentist choose a resin restoration, the balance of the cost for the resin restoration is Your responsibility.

Mouth Rehabilitation: If You and Your Group Dentist choose a course of Mouth Rehabilitation, only the procedures that are Medically Necessary to eliminate oral disease and replace missing teeth are covered. The rest of the charges are Your responsibility.

E. Oral Surgery Provides benefits for the following Oral Surgery and simple extractions.

1. Routine extractions.

2. Surgical extractions.

3. Apicoectomy - Excision of Apex of tooth root.

4. Removal of exostosis of the maxilla or mandible.

5. Incision and drainage of abscess -intraoral soft tissue.

6. Gingivectomy or Gingivoplasty - Excision of loose gum tissue to eliminate infection.

7. Gingival curettage.

8. Gingival flap procedure, including root planing.

9. Osseous surgery.

10. Alveoloplasty - The leveling of structures supporting teeth or the purpose of fitting dentures.

11. Frenectomy - Incision of any mid-line fold of tissue between the jaws and lips and between the lower jaw and tongue.

12. Removal of retained (residual) root.

13. Removal of exposed roots.

14. Surgical exposure of impacted or unerrupted teeth.

F. Endodontics

Pulpal and root canal therapy.

G. Periodontics

Surgical treatment is limited to the oral surgery procedures and benefits listed in the Oral Surgery Section.

Covered non-surgical procedures include periodontal scaling and root planing, periodontal scaling performed in the presence of gingival inflammation, periodontal maintenance procedures following active therapy, and other non-surgical periodontal procedures except as specifically excluded in General Exclusions.

H. Prosthodontics

1. Initial insertion of fixed partial denture (including inlays and crowns as abutments).

COVERED SERVICES D-13

2. Initial insertion of partial or full removable dentures (including any adjustments). Precision attachments are covered only when they replace an existing precision attachment.

3. Replacement of an existing removable partial, full denture or fixed bridge by a new removable partial, full denture or a fixed bridge. The addition of teeth to an existing removable partial denture or to a bridge. Replacement of prosthodontic appliances is covered only if at least five

(5) years have elapsed since the insertion of the existing appliance.

4. Stress breakers are covered only if they replace existing stress breakers.

Partial or Complete Dentures: Benefits are limited to the procedures that are Medically Necessary to eliminate oral disease and restore missing teeth. This means that if standard procedures and materials would give a satisfactory result, but You and Your Group Dentist choose specialized techniques, the balance of the cost for the specialized technique is Your responsibility.

You pay any Laboratory Charges at the time of service.

I. Orthodontics

Orthodontic diagnostic procedures and treatment consisting of appliance therapy to treat malocclusion.

You must pay a Co-insurance of 50% of the fee for each orthodontic treatment, up to $695.

Each Participant is entitled to orthodontic treatment under this Contract subject to any applicable Deductible, Co-insurance or Co-payment as outlined herein.

We provide orthodontic benefits only when the orthodontist believes a satisfactory result can be achieved. Cross bite in permanent teeth is treated only when the orthodontist believes other conditions make orthodontic treatment necessary.

If a Participant needs multiple orthodontic treatments which are separated from each other by more than eighteen (18) months of retention therapy, the Participant will be required to pay new Co-insurance for the successive treatment, and any maximum benefit is restored.

You are responsible to pay the cost of repair or replacement of an orthodontic appliance. If You choose braces other than standard metal braces, We pay the applicable percentage of the cost of the metal braces. You pay the balance.

If orthodontic treatment is terminated for any reason before completion, Our obligation to provide benefits ceases with the date of termination. If services are resumed, benefits for the services, to the extent remaining, resume.

WHILE UNDER THE CARE AND

TREATMENT OF DENTISTS OTHER

THAN GROUP DENTISTS

You may receive Dental Services from a Dentist who is not a Group Dentist in the following cases:

1. Referral by Dental Group

If Your Group Dentist decides You need covered Dental Service not available from the Dental Group, the Dental Group will give You a written referral. You are then entitled to covered Dental Services as specified by the written referral rendered by the Dentist to whom You were referred.

2. Emergency Services

Emergency Services performed outside the Service Area are covered up to $50. You should receive follow-up care at Your assigned Dental Group. To obtain payment for Emergency Services, submit an itemized bill to Your Dental Group.

D-14 GENERAL EXCLUSIONS

6 GENERAL EXCLUSIONS

Benefits do not include:

1. Dental Services not specifically described in this Contract.

2. Dental Services which are not Medically Necessary.

3. Dental Services which are Experimental/Investigational.

4. Services or supplies which are otherwise Dental Services, when such services or supplies are furnished in connection with or as a result of a non-covered dental service.

5. Dental Services and Emergency Services with respect to congenital malformations or those primarily for cosmetic, or beautifying purposes. (This exclusion applies to existing teeth and not to congenitally missing teeth.).

6. Any Laboratory Charges, except when specifically provided in the contract.

7. Charges for any duplicate prosthetic device or other appliance; replacement of lost or stolen devices or appliances; the replacement of an orthodontic appliance.

8. Placement of bone grafts or extra-oral substances; treatment of cleft palate or anodontia; orthognathic surgery, including osteotomy procedures and LeForte I, II, and III procedures.

9. Bacteriologic studies, caries susceptibility tests, histopathologic examinations, and other oral pathologic procedures.

10. Gold foil restorations, or implants.

11. The cost of high noble metals, unless Medically Necessary to restore the tooth.

12. Any splinting procedure.

13. General anesthesia; injections of antibiotic drugs, IV sedation except when specifically provided in the Contract.

14. Free care or care for which a Participant would have no legal obligation to pay without this or any similar coverage.

15. Dental Service or Emergency Service

a. that would be furnished to the Participant without charge;

b. which the Participant would be entitled to have furnished or paid for, fully or partially, under any law, regulations or agency of any government; if this Contract were not in effect.

16. Dental Services or Emergency Services to the extent Medicare is the Participant’s primary payor. Medicare is primary except where it is secondary payor by law. Where Medicare is primary, if the Participant does not apply for Medicare or comply with Medicare requirements, We will reduce Our benefits by the amount Medicare would have paid if the Participant had enrolled or complied.

17. Dental Service for temporomandibular joint (TMD) dysfunction or vertical dimension;

appliances, restorations, or procedures to adjust vertical dimension or restore occlusion.

18. Dental Services and Emergency Services for or resulting from, injuries, diseases or conditions which occur in the course of employment and for which a Participant is eligible for compensation under any Workers’ Compensation Act or Employer Liability Law. This applies whether or not the Participant recovers losses from a third party.

19. Dental Services resulting from diseases contracted or injuries sustained as a result of war, enemy action, or action of or serving in the Armed Forces of the United States or its allies or while serving in the Armed Forces of any country.

HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED D-15

20. Dental Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, academic institution or similar person or group.

21. Dental Services furnished prior to the Participant’s Effective Date.

22. Dental Services and Emergency Services rendered or furnished after the date a Participant ceases to be covered. This does not include:

a. procedures (other than prosthetic services) commenced before, and completed in 1 visit within thirty-one

(31) days following termination of coverage; or

b. prosthetic devices ordered and fitted before, and completed within sixty (60) days following termination of coverage.

23. Charges for telephone consultation, or the completion of insurance or a return to work/school forms and charges for failure to keep a scheduled visit with the Dentist;

charges which have not been documented in provider records.

24. Hospital or physician services of any kind.

25. Additional orthodontic fees that are a direct result of lack of patient cooperation, including without limitation missed appointments and failure to wear appliances.

26. Federal, state, and local taxes on goods or services.

27. Dental Services or Emergency Services rendered by a member of the Participant’s immediate family. Immediate family means the Participant’s spouse, children, parents, grandparents, brothers and sisters and their spouses.

28. Reimbursement to the Participant or any dental office for the cost of Dental Services obtained from Dentists who are not Dental Group Dentists, unless the Dental Group authorizes in writing the Dental Services.

29. Any portion of a provider’s charge which is more than the Maximum Allowed Amount We approve for payment.

LIMITATIONS

1. Your DENTACARE Center may restrict access to care if You fail to pay the required Co-insurance, Co-payment, or Deductible for Dental Services, Laboratory Charges, and charges for non-covered services. This limitation does not apply if a dental emergency exists. This restriction on access to care may be considered an unsatisfactory dentist-patient relationship which could lead to disenrollment.

2. This Contract does not cover any service, or a related service, which is a benefit under a hospital and/or surgical-medical group benefit plan offered by the same Group that covers the Participant.

7 HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED

General

This section describes how We determine the amount of reimbursement for Dental Services.

Reimbursement for dental services rendered by Network and Non-Network Dentists is based on this Booklet’s Maximum Allowed Amount for the type of service performed.

The Maximum Allowed Amount for this Booklet is the maximum amount of reimbursement We will pay for services and supplies:

• that meet Our definition of Dental Services, to the extent such services and supplies are covered under your plan and are not excluded;

D-16 HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED

• that are Medically Necessary; and

• that are provided in accordance with all applicable preauthorization, utilization management or other requirements set forth in your Booklet.

You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance. In addition, when you receive Dental Services from a Non-Network Dentist, you may be responsible for paying any difference between the Maximum Allowed Amount and the Dentist’s actual charges. This amount can be significant.

When you receive Dental Services from a Dentist, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Dental Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the dental procedure. Applying these rules may affect Our determination of the Maximum Allowed Amount. Our application of these rules does not mean that the Dental Services you received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, your Dentist may have submitted the claim using several procedure codes when there is a single procedure code that includes all or a combination of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code.

Likewise, when multiple procedures are performed on the same day by the same Dentist or other dental providers, We may reduce the Maximum Allowed Amounts for those additional procedures because reimbursement at 100% of the Maximum Allowed Amount for those procedures would represent a duplicate payment for a dental procedure that may have already been considered incidental or inclusive.

Provider Network Status The Maximum Allowed Amount may vary depending upon whether the Dentist is a Network Dentist or a Non-Network Dentist.

Network Dentist A Network Dentist or participating Dentist is a Dentist who is in the contracted network for this specific Booklet or who has a participation contract with Us. For Dental Services performed by a Network Dentist or participating providers, the Maximum Allowed Amount for this Booklet is the rate the Dentist has agreed with Us to accept as reimbursement for the Dental Services. Because Network Dentists and participating providers have agreed to accept the Maximum Allowed Amount as payment in full for those Dental Services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible, or have a copay or coinsurance. Please call Customer Service for help in finding a Network Dentist or participating provider or visit www.anthem.com.

Non-Network Dentist Dentists who have not signed any contract with Us and are not in any of Our networks are Non-Network Dentists. Certain benefits are not available when received from Non-Network Dentists. Please see the rest of this Booklet for details.

For Dental Services You receive from a Non-Network Dentist, the Maximum Allowed Amount for this Booklet will be one of the following as determined by Us:

1. An amount based on Our managed care fee schedules used with Network Dentists, which We reserve the right to modify from time to time; or

2. An amount based on information provided by a third party vendor which may reflect

COORDINATION OF THE CONTRACT’S BENEFITS WITH OTHER BENEFITS D-17

comparable Dentists’ fees and costs to deliver care; or

3. An amount negotiated by Us or a third party vendor which has been agreed to by the Network Dentist; or

4. An amount equal to the total charges billed by the Dentist, but only if such charges are less than the Maximum Allowed Amount calculated by using one of the methods described above.

Dentists who are not contracted for this product but contracted for other products with Us are also considered Non-Network. For this Booklet, the Maximum Allowed Amount for services from these Dentists will be one of the four methods shown above unless the contract between Us and that Dentist specifies a different amount.

Unlike Network Dentists or participating providers, Non-Network Dentists may send You a bill and collect for the amount of the Dentist’s charge that exceeds Our Maximum Allowed Amount. You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Dentist charges. This amount can be significant. Choosing a Network Dentist or participating Dentist will likely result in lower out of pocket costs to you. Please call Customer Service for help in finding a Network Dentist or visit Our website at www.anthem.com.

Customer Service is also available to assist you in determining this Booklet’s Maximum Allowed Amount for a particular service from a Non-Network Dentist. In order for Us to assist you, you will need to obtain from your Dentist the specific procedure code(s) for the services the Dentist will render. You will also need to know the Dentist’s charges to calculate your out of pocket responsibility. Although Customer Service can assist you with this pre-service information, the final Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Dentist.

Member Cost Share For certain Dental Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or Coinsurance).

We will not provide any reimbursement for non-covered services. You may be responsible for the total amount billed by your Dentist for non-covered services, regardless of whether such services are performed by a Network or Non-Network Dentist. Both services specifically excluded by the terms of your Booklet and those received after benefits have been exhausted are non-covered services. Benefits may be exhausted by exceeding, for example, your annual or lifetime maximum, benefit maximums or day/visit limits.

8 COORDINATION OF THE CONTRACT’S BENEFITS WITH OTHER

BENEFITS

APPLICABILITY

This Coordination of Benefits ("COB") provision applies to This Plan when a Member has dental care coverage under more than one Plan, except to the extent this provision is superseded by the Medicare secondary payor rules. "Plan" and "This Plan" are defined below.

If this COB provision applies, the order of benefit determination rules are looked at first. The rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits of This Plan:

1. Are not reduced when, under the order of benefit determination rules, This Plan determines its benefits before another…