San Bernardino County - 2026 Active and Retiree Dental RFP Workbook~1.xlsb
XLSB spreadsheet 148 KB Posted
- Solicitation number
- HRD127-HR-6551
- Issued by
- San Bernardino County, California
About this file
This is a Request for Proposal (RFP) workbook prepared by Segal for San Bernardino County to solicit dental benefits coverage for active employees and retirees. The RFP seeks proposals for four distinct dental plan options: Active Self-Insured DPPO (Dental Preferred Provider Organization), Active Fully-Insured DHMO (Dental Health Maintenance Organization), Retiree Fully-Insured DPPO with Low and High options, and Retiree Fully-Insured DHMO. The Active DPPO plan is effective July 24, 2027 through July 16, 2032, while Retiree plans commence January 1, 2028 through December 31, 2032. Bidders must submit responses in Excel format using the provided workbook exhibits, with specific requirements for pricing, benefit designs, and performance guarantees. The RFP allows for both a five-year rate guarantee and a three-year initial rate guarantee with optional years four and five. Vendors are required to complete all exhibits without altering, adding, or deleting pre-labeled rows, and failure to comply may result in proposal rejection.
Pricing submissions must include bi-weekly and monthly ASO (Administrative Services Only) fees for the Active DPPO plan and monthly rates for all other plans, with options for rate guarantees and not-to-exceed rate caps for years four and five. The workbook includes detailed benefit design specifications across multiple service categories including preventive, restorative, endodontic, periodontic, prosthodontic, oral surgery, and orthodontic services, with specific copay structures for the DHMO options and coinsurance percentages for DPPO options. Performance guarantees totaling 19 percent of administration at risk are required across eleven categories including account management, eligibility processing, claims turnaround, claims accuracy, customer service, contract renewal notification, quality management, customer satisfaction, network stability, group reporting, and ID card distribution. The RFP allows vendors to propose alternative benefit designs, particularly an enhanced annual maximum option increasing from $1,700 to $2,000 for Class II and III expenses, and vendors may include supplemental underwriting materials alongside required exhibits.
Text of this file
Instructions
| Dental RFP — Workbook |
| Instructions |
| Exhibit Instructions to Vendors |
| 1. Do not delete or alter pre-labeled rows. |
| 2. Electronic copies of these exhibits must be returned in Excel. Do not provide in a PDF format. |
| 3. Do not extract individual worksheets (exhibits) and submit as separate Excel workbooks in the electronic copy. |
| 4. Cells shaded light gold are expected inputs. Please review these carefully for a response. |
You may additionally include your normal underwriting pricing worksheets and caveats. However, we will use your responses on the required exhibits and questionnaire as your proposal response when they differ from any supplemental underwriting materials you provide.
| Copyright © 2026 by Segal. All rights reserved. |
| Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. |
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Actives
Act DPPO-Pricing
| San Bernardino County — Dental RFP |
| Attachment E - Cost |
| Active Self-Insured DPPO Plan |
If bidding, this form must be completed in its entirety. Please do not alter, add or delete rows. Failure to complete this exhibit as requested may results in rejection of your offer.
| 5-Year Rate Guarantee | |
| 5 Year Guarantee | |
| Active DPPO | 07/24/2027 - 07/16/2032 |
| Column1 | Column12 |
| DPPO Plan – Self Insured - Current Benefits | |
| ASO Fees - Bi-weekly | |
| ASO Fees - Monthly |
| 3-Year Initial Rate Guarantee with Option Years | |||
| 3 Year Guarantee | Year 4 | Year 5 | |
| Active DPPO | 07/24/2027 - 07/19/2030 | 07/20/2030 - 07/18/2031 | 07/19/2031 - 07/16/2032 |
| Column1 | Column2 | Column3 | Column4 |
| DPPO Plan – Self Insured - Current Benefits | |||
| ASO Fees - Bi-weekly | |||
| ASO Fees - Monthly | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) |
| Impact to Claims (%) | |
| DPPO Plan Changes - Alternative Option 1 | |
| Annual Maximum (Class II and III) increase from $1,700 to $2,000 for both IN and OON | |
| Copyright © 2026 by Segal. All rights reserved. | |
| Unauthorized replication or use of this financial workbook is prohibited. | |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. | |
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Act DHMO-Pricing
| San Bernardino County — Dental RFP |
| Attachment E - Cost |
| Active Fully-Insured DHMO Plan |
If bidding, this form must be completed in its entirety. Please do not alter, add or delete rows. Failure to complete this exhibit as requested may results in rejection of your offer.
| 5-Year Rate Guarantee | |||
| 5 Year Guarantee | |||
| Active DHMO | 07/24/2027 - 07/16/2032 | ||
| Column1 | Column12 | ||
| DHMO Plan - Fully-Insured Bi-weekly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| DHMO Plan - Fully-Insured Monthly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| 3-Year Initial Rate Guarantee with Option Years | |||
| 3 Year Guarantee | Year 4 | Year 5 | |
| Active DHMO | 07/24/2027 - 07/19/2030 | 07/20/2030 - 07/18/2031 | 07/19/2031 - 07/16/2032 |
| Column1 | Column2 | Column3 | Column4 |
| DHMO Plan - Fully-Insured Bi-weekly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| DHMO Plan - Fully-Insured Monthly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| Copyright © 2026 by Segal. All rights reserved. | |||
| Unauthorized replication or use of this financial workbook is prohibited. | |||
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. | |||
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Act DPPO-CurrentBenefits
| San Bernardino County — Dental RFP |
| Attachment N – Dental Plan Benefit Design Summary |
| Actives Self-Insured DPPO Benefit Summary |
Complete the grid indicating any difference in benefit design offered. Please leave cells BLANK if proposed plan design offered is the same as requested.
| Current | Proposed (Deviations Only) | |||||
| Plan Design | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Networks | PPO Tier 1 (PPO) | PPO Tier 2 (Premier) and Non-Contracted Providers | ||||
| Deductible | None | None | ||||
| Annual Maximum (Class II and III Expenses) | $1,700 per person | $1,700 per person | ||||
| Orthodontia Lifetime Maximum (Class IV) | $1,700 per person | $1,700 per person | ||||
| Orthodontia Adult or Child Coverage | Covered for Eligible Adults and Dependents | Covered for Eligible Adults and Dependents | ||||
| Reimbursement Levels | Based on Reduced Contracted Fees | Based on the 80th percentile of UCR allowances | ||||
| Class I - Preventive & Diagnostic | ||||||
| Oral Exams | 100% | 100% | ||||
| Routine Cleanings | 100% | 100% | ||||
| Full Mouth X-rays | 100% | 100% | ||||
| Bitewing X-rays | 100% | 100% | ||||
| Panoramic X-ray | 100% | 100% | ||||
| Periapical X-rays | 100% | 100% | ||||
| Fluoride Application | 100% | 100% | ||||
| Space Maintainers | 100% | 100% | ||||
| Emergency Care to Relieve Pain | 100% | 100% | ||||
| Class II - Basic Restorative | ||||||
| Fillings | 100% | 90% | ||||
| Root Canal Therapy/Endodontics | 100% | 90% | ||||
| Denture Adjustments and Repairs | 100% | 90% | ||||
| Oral Surgery | 100% | 90% | ||||
| Repairs to Crowns and Inlays | 100% | 90% | ||||
| Surgical Extractions of Impacted Teeth | 100% | 90% | ||||
| Anesthetics | 100% | 90% | ||||
| Simple extractions | 100% | 90% | ||||
| Class III - Major Restorative | ||||||
| Crowns | 75% | 70% | ||||
| Inlays/Onlays | 75% | 70% | ||||
| Prosthesis Over Implant | 75% | 70% | ||||
| Dentures | 75% | 70% | ||||
| Bridges | 75% | 70% | ||||
| Class IV - Orthodontia | 50% | 50% | ||||
| Class VI | ||||||
| Major & Minor Periodontics | 90% | 90% | ||||
| Anesthesia | 90% | 90% | ||||
| Sealants | 90% | 90% | ||||
| Class IX - Surgical Implants | 75% | 70% | ||||
| Enhanced Benefits for Participants with one of the following chronic inflammation-related medical conditions: Diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis | ||||||
| D4341: One Scaling and Root Planing | 100% Once every | |||||
| calendar year | 100% Once every |
calendar year
| Four of the following (any combination) per calendar year: | ||
| D1110 or D1120: Prophylaxis (teeth cleaning) | 100% | 100% |
| D4346: Scaling in presence of moderate or severe gingival inflammation | 100% | 100% |
| D4910: Periodontal maintenance procedure | 100% | 100% |
Comments:
| Copyright © 2026 by Segal. All rights reserved. |
| Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. |
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Act DPPO-Benefits_Opt 1
| San Bernardino County — Dental RFP |
| Attachment N – Dental Plan Benefit Design Summary |
| Actives Self-Insured DPPO Benefit Summary (Increase Annual Maximum) |
Complete the grid indicating any difference in benefit design offered. Please leave cells BLANK if proposed plan design offered is the same as requested.
| Alternative Option 1 | Proposed (Deviations Only) | |||||
| Plan Design | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Networks | PPO Tier 1 (PPO) | PPO Tier 2 (Premier) and Non-Contracted Providers | ||||
| Deductible | None | None | ||||
| Annual Maximum (Class II and III Expenses) | $2,000 per person | $2,000 per person | ||||
| Orthodontia Lifetime Maximum (Class IV) | $1,700 per person | $1,700 per person | ||||
| Orthodontia Adult or Child Coverage | Covered for Eligible Adults and Dependents | Covered for Eligible Adults and Dependents | ||||
| Reimbursement Levels | Based on Reduced Contracted Fees | Based on the 80th percentile of UCR allowances | ||||
| Class I - Preventive & Diagnostic | ||||||
| Oral Exams | 100% | 100% | ||||
| Routine Cleanings | 100% | 100% | ||||
| Full Mouth X-rays | 100% | 100% | ||||
| Bitewing X-rays | 100% | 100% | ||||
| Panoramic X-ray | 100% | 100% | ||||
| Periapical X-rays | 100% | 100% | ||||
| Fluoride Application | 100% | 100% | ||||
| Space Maintainers | 100% | 100% | ||||
| Emergency Care to Relieve Pain | 100% | 100% | ||||
| Class II - Basic Restorative | ||||||
| Fillings | 100% | 90% | ||||
| Root Canal Therapy/Endodontics | 100% | 90% | ||||
| Denture Adjustments and Repairs | 100% | 90% | ||||
| Oral Surgery | 100% | 90% | ||||
| Repairs to Crowns and Inlays | 100% | 90% | ||||
| Surgical Extractions of Impacted Teeth | 100% | 90% | ||||
| Anesthetics | 100% | 90% | ||||
| Simple extractions | 100% | 90% | ||||
| Class III - Major Restorative | ||||||
| Crowns | 75% | 70% | ||||
| Inlays/Onlays | 75% | 70% | ||||
| Prosthesis Over Implant | 75% | 70% | ||||
| Dentures | 75% | 70% | ||||
| Bridges | 75% | 70% | ||||
| Class IV - Orthodontia | 50% | 50% | ||||
| Class VI | ||||||
| Major & Minor Periodontics | 90% | 90% | ||||
| Anesthesia | 90% | 90% | ||||
| Sealants | 90% | 90% | ||||
| Class IX - Surgical Implants | 75% | 70% | ||||
| Enhanced Benefits for Participants with one of the following chronic inflammation-related medical conditions: Diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis | ||||||
| D4341: One Scaling and Root Planing | 100% Once every | |||||
| calendar year | 100% Once every |
calendar year
| Four of the following (any combination) per calendar year: | ||
| D1110 or D1120: Prophylaxis (teeth cleaning) | 100% | 100% |
| D4346: Scaling in presence of moderate or severe gingival inflammation | 100% | 100% |
| D4910: Periodontal maintenance procedure | 100% | 100% |
Comments:
| Copyright © 2026 by Segal. All rights reserved. |
| Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. |
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Act DHMO-Benefits
| San Bernardino County — Dental RFP |
| Attachment N – Dental Plan Benefit Design Summary |
| Active Fully-Insured DHMO Plan |
Complete the grid indicating any difference in benefit design offered. Please leave cells BLANK if proposed plan design offered is the same as requested.
CDT Code Procedure Description Current Member Copay Proposed (Deviations Only)
| Diagnostic Services | ||
| D0120 | Periodic Oral Evaluation | $0 |
| D0140 | Limited Oral Evaluation | $0 |
| D0145 | Oral Evaluation for patients under age 3 and counseling with primary caregiver | $0 |
| D0150 | Comprehensive Oral Evaluation | $0 |
| D0160 | Detailed and extensive oral evaluation | $0 |
| D0170 | Re-evaluation- limited, problem focused | $0 |
| D0171 | Re-evaluation-post operative office visit | $5 |
| D0180 | Comprehensive Periodontal Evaluation | $0 |
| D0190 | Screening of a patient | $0 |
| D0191 | Assessment of a patient | $0 |
| D0210 | Intraoral - Complete (Including Bitewings) | $0 |
| D0220 | Intraoral - Periapical First Film | $0 |
| D0230 | Intraoral - Periapical Each Add'l Film | $0 |
| D0240 | Inraoral occlusal radiographic image | $0 |
| D0250 | Extraoral-2D projection radiographic image | $0 |
| D0251 | Extraoral posterior dental radiographic image | $0 |
| D0270 | Bitewing-single radiographic image | $0 |
| D0272 | Bitewings - 2 Films | $0 |
| D0273 | Bitewings-three radiographic images | $0 |
| D0274 | Bitewings - 4 Films | $0 |
| D0277 | Vertical bitewings- 7 to 8 radiographic images | $0 |
| D0330 | Panoramic Film | $0 |
| D0414 | Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report | $0 |
| D0415 | Collection of microorganisms for culture and sensitivity | $0 |
| D0419 | Assessment of salivary flow by measurement – 1 every 12 months | $0 |
| D0425 | Caries susceptibility tests | $0 |
| D0460 | Pulp vitality tests | $0 |
| D0470 | Diagnostic costs | $0 |
| D0472 | Accession of tissue, gross examination, preparation and transmission of written report | $0 |
| D0473 | Accession of tissue, gross and microscopic examination, preparation and transmission of written report | $0 |
| D0474 | Accession of tissue, gross and microscopic, including assessment of surgical margins for presence of disease, preparation and transmission of written report | $0 |
| D0601 | Caries risk assessment and documentation, with a finding of low risk- 1 every 12 months | $0 |
| D0602 | Carries risk assessment and documentation, with findings of moderate risk, 1 every 12 months | $0 |
| D0603 | Carries risk assessment and documentation, with findings of high risk- 1 every 12 months | $0 |
| D0701 | Panoramic radiographic image-image capture only | $0 |
| D0702 | 2-D cephalometric radiographic image | $0 |
| D0703 | 2-D oral/facial photographic image | $0 |
| D0704 | 3-D photographic image-image capture only | $0 |
| D0705 | Extra-oral posterior dental radiographic image | $0 |
| D0706 | Intraoral-occlusal radiographic image | $0 |
| D0707 | Intraoral-periapical radiographic image | $0 |
| D0708 | Intraoral-bitewing radiographic image | $0 |
| D0709 | Intraoral-complete series of radiographic image | $0 |
| D0999 | Unspecified Diagnostic Procedure | $0 |
| Preventive Services | ||
| D1110 | Prophylaxis – Adult (Up to 4 cleanings per calendar year for patients with diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis, No Cost) | $0 |
| D1110 | Additional prophylaxis cleaning-adult (in addition to the 2 allowed per calendar year) | $45 |
| D1120 | Prophylaxis – Child (Up to 4 cleanings per calendar year for patients with diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis, No Cost) | $0 |
| D1120 | Additional prophylaxis cleanings-child (in addition to the 2 allowed per calendar year) | $35 |
| D1206 | Topical Fluoride Varnish | $0 |
| D1208 | Topical Application of Fluoride-excluding varnish | $0 |
| D1310 | Nutritional counseling for control of dental disease | $0 |
| D1330 | Oral Hygiene Instructions | $0 |
| D1351 | Sealant - Per Tooth | $5 |
| D1353 | Sealant repair-per tooth | $3 |
| D1354 | Interim caries arresting medicament application-per tooth, 2 per cal year | $0 |
| D1510 | Space maintainer-fixed- unilateral-per quadrant | $15 |
| D1516 | Space maintainer-fixed-bilateral, maxillary | $15 |
| D1517 | Space maintainer-fixed-bilateral, mandibular | $15 |
| D1520 | Space maintainer-removable-unilateral, per quadrant | $15 |
| D1526 | Space maintainer-removable-bilateral, maxillary | $15 |
| D1527 | Space maintainer-removable-bilateral, mandibular | $15 |
| D1551 | Re-cement or re-bond bilateral space maintainer-maxillary | $0 |
| D1552 | Re-cement or re-bond bilateral space maintainer-mandibular | $0 |
| D1553 | Re-cement or re-bond unilateral space maintainer-per quadrant | $0 |
| D1556 | Removal of fixed unilateral space maintainer-per quadrant | $0 |
| D1557 | Removal of fixed bilateral space maintainer-maxillary | $0 |
| D1558 | Removal of fixed bilateral space maintainer-mandibular | $0 |
| D1575 | Distal shoe space maintainer-fixed, unilateral, per quadrant, child to age 9 | $17 |
| Restorative Services | ||
| No additional fees may be charged to the patient for name brand, laboratory processed or in-office processed crowns/pontics, inlays, onlays, post and cores, and or veneers if produced through specialized technique or materials, including but not limited to: (Captek, Procera, Zirconia, Lava, Empress and Cerec) | Agree (Yes/No) | |
| D2140 | Amalgam - 1 Surface Primary or Permanent | $0 |
| D2150 | Amalgam - 2 Surfaces Primary or Permanent | $0 |
| D2160 | Amalgam - 3 Surfaces Primary or Permanent | $0 |
| D2161 | Amalgam - 4 or More Surfaces Primary or Permanent | $0 |
| D2330 | Resin-Based Composite - 1 Surface Anterior | $0 |
| D2331 | Resin-Based Composite - 2 Surfaces Anterior | $0 |
| D2332 | Resin-Based Composite - 3 Surfaces Anterior | $0 |
| D2335 | Resin-Based Composite - 4+ Surfaces/Incisal Angle | $0 |
| D2390 | Resin-Based crown, anterior | $0 |
| D2391 | Resin-Based Composite - 1 Surface Posterior | $45 |
| D2392 | Resin-Based Composite - 2 Surfaces Posterior | $55 |
| D2393 | Resin-Based Composite - 3 Surfaces Posterior | $65 |
| D2394 | Resin-Based Composite - 4+ Surfaces Posterior | $75 |
| D2510 | Inlay-metallic-one surface | $0 |
| D2520 | Inlay-metallic-two surface | $0 |
| D2530 | Inlay-metallic-three or more surfaces | $0 |
| D2542 | Onlay-metallic-two surfaces | $0 |
| D2543 | Onlay-metallic-three surfaces | $0 |
| D2544 | Onlay-metallic-four or more surfaces | $0 |
| D2610 | Inlay-porcelain/ceramic-one surfaces | $135 |
| D2620 | Inlay-porcelain/ceramic-two surfaces | $150 |
| D2630 | Inlay-porcelain/ceramic-three or more surfaces | $160 |
| D2642 | Onlay-porcelain/ceramic-two surfaces | $150 |
| D2643 | Onlay-porcelain/ceramic-three surfaces | $165 |
| D2644 | Onlay-porcelain/ceramic-four or more surfaces | $175 |
| D2650 | Inlay-resin-based composite-one surface | $85 |
| D2651 | Inlay-resin-based composite-two surfaces | $95 |
| D2652 | Inlay-resin-based composite-three or more surfaces | $115 |
| D2662 | Onlay-resin-based composite-two surfaces | $110 |
| D2663 | Onlay-resin-based composite-three surfaces | $120 |
| D2664 | Onlay-resin-based composite-four of more surfaces | $145 |
| D2710 | Crown-resin-based composite (indirect) | $40 |
| D2712 | Crown-3/4 resin-based composite (indirect) | $40 |
| D2720 | Crown-resin with high noble metal | $160 |
| D2721 | Crown-resin with predominantly base metal | $60 |
| D2722 | Crown-resin with noble metal | $60 |
| D2740 | Crown - Porcelain/Ceramic Substrate | $60 |
| D2750 | Crown - Porcelain Fused, High Noble Metal | $160 |
| D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $60 |
| D2752 | Crown - Porcelain Fused to Noble Metal | $60 |
| D2753 | Crown-Porcelain fused to titanium and titanium alloys | $160 |
| D2780 | Crown-3/4 cast high noble metal | $160 |
| D2781 | Crown-3/4 cast predominantly base metal | $60 |
| D2782 | Crown-3/4 cast noble metal | $60 |
| D2783 | Crown-3/4 porcelain/ceramic | $195 |
| D2790 | Crown-full cast high noble metal | $160 |
| D2791 | Crown-full cast predominantly base metal | $60 |
| D2792 | Crown-full cast noble metal | $60 |
| D2794 | Crown-titanium and titanium alloys | $160 |
| D2910 | Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration | $0 |
| D2915 | Re-cement or re-bond indirectly fabricated or prefabricated post and core | $0 |
| D2920 | Re-cement or re-bond Crown | $0 |
| D2921 | Reattachment of tooth fragment, incisal edge or cusp (anterior) | $0 |
| D2928 | Prefabricated porcelain/ceramic crown-permanent tooth | $0 |
| D2929 | Prefabricated porcelain/ceramic crown-primary tooth-anterior | $10 |
| D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $0 |
| D2931 | Prefabricated stainless steel crown-Permanent Tooth | $0 |
| D2932 | Prefabricated resin crown-anterior primary tooth | $10 |
| D2933 | Prefabricated stainless steel crown with resin window-anterior primary tooth | $10 |
| D2940 | Protective restoration | $10 |
| D2949 | Restorative foundation for an indirect restoration | $10 |
| D2950 | Core Buildup, including Any Pins | $10 |
| D2951 | Pin retention-per tooth, in addition to restoration | $10 |
| D2952 | Post & Core In Addition To Crown, Indirect Fabricated | $10 |
| D2953 | Each additional indirectly fabricated post-same tooth-includes canal preparation | $10 |
| D2954 | Prefabricated Post & Core In Addition To Crown | $10 |
| D2957 | Each additional prefabricated post-same tooth-base metal post; includes canal preparation | $10 |
| D2971 | Additional procedures to construct new crown under existing partial denture framework | $12 |
| D2980 | Crown repair necessitated by restorative material failure | $10 |
| D2981 | Inlay repair necessitated by restorative material failure | $10 |
| D2982 | Onlay repair necessitated by restorative material failure | $10 |
| D2983 | Veneer repair necessitated by restorative material failure | $10 |
| D2990 | Resin infiltration of incipient smooth surface lesions-limited to permanent molars | $5 |
| Endodontic Services | ||
| D3110 | Pulp-cap-direct (excluding final restoration) | $0 |
| D3120 | Pulp-cap-indirect (excluding final restoration) | $0 |
| D3220 | Therapeutic pulpotomy (excluding final restoration)-removal of pulp coronal to the dentin0cemental junction and application of medicament | $0 |
| D3221 | Pulpal debridement, primary and permanent teeth | $6 |
| D3222 | Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development | $0 |
| D3230 | Pulpal therapy (resorbable filling)-anterior, primary tooth | $6 |
| D3240 | Pulpal therapy (resorbable filling)-posterior, primary tooth | $6 |
| D3310 | Anterior (Excluding Final Restoration) | $30 |
| D3320 | Bicuspid (Excluding Final Restoration) | $60 |
| D3330 | Molar (Excluding Final Restoration) | $90 |
| D3331 | Treatment of Root Canal Obstruction | $45 |
| D3332 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | $45 |
| D3333 | Internal root repair or perforation defects | $45 |
| D3346 | Retreatment of previous root canal therapy-anterior | $45 |
| D3347 | Retreatment of previous root canal therapy-premolar | $75 |
| D3348 | Retreatment of Previous Root Canal Therapy - Molar | $105 |
| D3351 | Apexification/recalcification-initial visit | $70 |
| D3352 | Apexification/recalcification-interim medication replacement | $45 |
| D3353 | Apexification/recalcification-final visit | $45 |
| D3410 | Apicoectomy-anterior | $50 |
| D3421 | Apicoectomy-premolar | $50 |
| D3425 | Apicoectomy-molar | $50 |
| D3426 | Apicoectomy (each additional root) | $0 |
| D3430 | Retrograde filling-per root | $50 |
| D3450 | Root amputation-per root | $0 |
| D3471 | Surgical repair of root resorption-anterior | $50 |
| D3472 | Surgical repair of root resorption-premolar | $50 |
| D3473 | Surgical repair of root resorption-molar | $50 |
| D3501 | Surgical exposure of root surface without apicoectomy or repair of root resorption-anterior | $50 |
| D3502 | Surgical exposure of root surface without apicoectomy or repair of root resorption-premolar | $50 |
| D3503 | Surgical exposure of root surface without apicoectomy or repair of root resorption-molar | $50 |
| D3920 | Hemisection, not including root canal therapy | $0 |
| Periodontic Services | ||
| D4210 | Gingivectomy or genioplasty-four or more contiguous teeth or tooth bounded spaces per quadrant | $75 |
| D4211 | Gingivectomy or genioplasty-one to three contiguous teeth or bounded spaces per quadrant | $15 |
| D4212 | Gingivectomy or genioplasty to allow access for restoration procedure, per tooth | $0 |
| D4240 | Gingival flap procedure, including root planning-four or more contiguous teeth or tooth bounded spaces-per quadrant | $75 |
| D4241 | Gingival flap procedure, including root planning-one to three contiguous teeth or tooth bounded spaces per quadrant | $75 |
| D4245 | Apically positioned flap | $75 |
| D4249 | Clinical crown lengthening-hard tissue | $75 |
| D4260 | Osseous Surgery, 4+Teeth per Quadrant | $150 |
| D4261 | Osseous Surgery (including elevation of a full thickness flap and closure-one to three contiguous teeth or tooth bounded spaces, per quadrant | $150 |
| D4263 | Bone replacement graft-first site in quadrant | $195 |
| D4264 | Bone replacement graft-each additional site in quad | $60 |
| D4270 | Pedicle soft tissue graft procedure | $195 |
| D4274 | Mesial/distal wedge procedure, single tooth | $45 |
| D4277 | Free soft tissue graft procedure, first tooth, implant, or edentulous tooth position in graft | $195 |
| D4278 | Free soft tissue graft procedure, each additional contiguous tooth, implant, or edentulous tooth position in same graft | $100 |
| D4341 | Periodontal Scaling & Root Planning, 4+ Teeth/Quad. | $0 |
| D4342 | Periodontal Scaling & Root Planning, 1 to 3 Teeth/Quad. | $0 |
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation-limited to 1 treatment in any 12 consecutive months | $0 |
| D4355 | Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit-limit to 1 treatment in any 12 consecutive months | $0 |
| D4910 | Periodontal Maintenance-limited to 2 per cal year (Up to 4 cleanings per calendar year for patients with diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis, No Cost) | $0 |
| D4910 | Additional periodontal maintenance (beyond 2 per cal year) | $55 |
| D4921 | Gingival irrigation-per quadrant | $0 |
| Removable Prosthodontics | ||
| D5110 | Complete Denture- maxillary | $75 |
| D5120 | Complete Denture-mandibular | $75 |
| D5130 | Immediate Denture-maxillary | $90 |
| D5140 | Immediate Denture-mandibular | $90 |
| D5211 | Maxillary partial denture-resin based | $85 |
| D5212 | Mandibular partial denture-resin based | $85 |
| D5213 | Upper Partial Denture - Cast Metal Framework | $85 |
| D5214 | Lower Partial Denture - Cast Metal Framework | $85 |
| D5221 | Immediate Maxillary Partial Denture - Resin Base | $90 |
| D5222 | Immediate Mandibular Partial Denture – Resin Base | $90 |
| D5223 | Immediate maxillary partial denture-cast metal framework with resin denture bases | $90 |
| D5224 | Immediate mandibular partial denture-cast metal framework with resin denture bases | $90 |
| D5225 | Maxillary partial denture-flexible base | $135 |
| D5226 | Mandibular partial denture-flexible base | $135 |
| D5410 | Adjust complete denture-maxillary | $0 |
| D5411 | Adjust complete denture-mandibular | $0 |
| D5421 | Adjust partial denture-maxillary | $0 |
| D5422 | Adjust partial denture-mandibular | $0 |
| D5511 | Repair broken complete denture base-mandibular | $15 |
| D5512 | Repair broken complete denture base-maxillary | $15 |
| D5520 | Replace missing or broken teeth-complete denture (each tooth) | $5 |
| D5611 | Repair resin partial denture base, mandibular | $15 |
| D5612 | Repair resin partial denture base, maxillary | $15 |
| D5621 | Repair cast partial framework, mandibular | $15 |
| D5622 | Repair cast partial framework, maxillary | $15 |
| D5630 | Repair or replace broken retentive/clasping materials (per tooth) | $15 |
| D5640 | Replace broken teeth-per tooth | $5 |
| D5650 | Add Tooth to Existing Partial Denture | $5 |
| D5660 | Add clasp to existing partial denture | $5 |
| D5670 | Replace all teeth and acrylic on cast metal framework-maxillary | $75 |
| D5671 | Replace all teeth and acrylic on cast metal framework-mandibular | $75 |
| D5710 | Rebase complete maxillary denture | $30 |
| D5711 | Rebase complete mandibular denture | $30 |
| D5720 | Rebase complete maxillary denture (chairside) | $30 |
| D5721 | Rebase complete mandibular denture (chairside) | $30 |
| D5730 | Reline complete maxillary denture (chairside) | $15 |
| D5731 | Reline complete mandibular denture (chairside) | $15 |
| D5740 | Reline maxillary partial denture (chairside) | $15 |
| D5741 | Reline mandibular partial denture (chairside) | $15 |
| D5750 | Reline complete maxillary denture (laboratory) | $30 |
| D5751 | Reline complete mandibular denture (laboratory) | $30 |
| D5760 | Reline maxillary partial denture (laboratory) | $30 |
| D5761 | Reline mandibular partial denture (laboratory) | $30 |
| D5820 | Interim partial denture, maxillary | $0 |
| D5821 | Interim partial denture, mandibular | $0 |
| D5850 | Tissue conditioning, maxillary | $0 |
| D5851 | Tissue conditioning, mandibular | $0 |
| Fixed Prosthodontics | ||
| No additional fees may be charged to the patient for name brand, laboratory processed or in-office processed crowns/pontics, inlays, onlays, post and cores, and or veneers if produced through specialized technique or materials, including but not limited to: (Captek, Procera, Zirconia, Lava, Empress and Cerec) | Agree (Yes/No) | |
| D6210 | Pontic-cast high noble metal | $160 |
| D6211 | Pontic-cast predominantly base metal | $60 |
| D6212 | Pontic-cast noble metal | $60 |
| D6240 | Pontic - Porcelain Fused to High Noble Metal | $160 |
| D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $60 |
| D6242 | Pontic-porcelain fused to noble metal | $60 |
| D6243 | Pontic-porcelain fused to titanium and titanium alloys | $60 |
| D6245 | Pontic-porcelain/ceramic | $195 |
| D6250 | Pontic-resin with high noble metal | $160 |
| D6251 | Pontic-resin with predominantly base metal | $60 |
| D6252 | Pontic-resin with noble metal | $60 |
| D6600 | Retainer inlay-porcelain/ceramic, two surfaces | $150 |
| D6601 | Retainer inlay-porcelain/ceramic, three or more surfaces | $160 |
| D6602 | Retainer inlay-cast high noble metal, two surfaces | $0 |
| D6603 | Retainer inlay-cast high noble metal, three or more surfaces | $0 |
| D6604 | Retainer inlay-cast predominantly base metal, two surfaces | $0 |
| D6605 | Retainer inlay-cast predominantly base metal, three or more surfaces | $0 |
| D6606 | Retainer inlay-cast noble metal, two surfaces | $0 |
| D6607 | Retainer inlay-cast noble metal, three or more surfaces | $0 |
| D6608 | Retainer onlay-porcelain/ceramic , two surfaces | $150 |
| D6609 | Retainer onlay-porcelain/ceramic, three or more surfaces | $165 |
| D6610 | Retainer onlay-cast high noble metal, two surfaces | $0 |
| D6611 | Retainer onlay-cast high noble metal, three or more surfaces | $0 |
| D6612 | Retainer onlay-cast predominantly base metal, two surfaces | $0 |
| D6613 | Retainer onlay-cast predominantly base metal, three or more surfaces | $0 |
| D6614 | Retainer onlay-cast noble metal, two surfaces | $0 |
| D6615 | Retainer onlay-cast noble metal, three or more surfaces | $0 |
| D6720 | Retainer crown-resin with high noble metal | $160 |
| D6721 | Retainer crown-resin with predominantly base metal | $60 |
| D6722 | Retainer crown-resin with noble metal | $60 |
| D6740 | Retainer crown-porcelain/ceramic | $195 |
| D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $160 |
| D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $60 |
| D6752 | Retainer crown- porcelain fused to noble metal | $60 |
| D6753 | Retainer crown-porcelain fused to titanium and titanium alloys | $160 |
| D6780 | Retainer crown-3/4 cast high noble metal | $160 |
| D6781 | Retainer crown-3/4 cast predominantly base metal | $60 |
| D6782 | Retainer crown-3/4 cast noble metal | $60 |
| D6783 | Retainer crown-3/4 porcelain/ceramic | $195 |
| D6784 | Retainer crown-titanium and titanium alloys | $160 |
| D6790 | Retainer crown-full cast noble metal | $160 |
| D6791 | Retainer crown-full cast predominantly base metal | $60 |
| D6792 | Retainer crown-full cast noble metal | $60 |
| D6930 | Re-cement or re-bond fixed partial denture | $0 |
| D6940 | Stress breaker | $0 |
| D6990 | Fixed partial denture repair necessitated by restorative material failure | $15 |
| Oral Surgery | ||
| D7111 | Extraction of Coronal Remnants, Deciduous Tooth | $0 |
| D7140 | Extraction, Erupted Tooth or Exposed Root | $0 |
| D7210 | Surgical Removal of Erupted Tooth | $0 |
| D7220 | Removal of impacted tooth-soft tissue | $0 |
| D7230 | Removal of Impacted Tooth - Partially Bony | $30 |
| D7240 | Removal of Impacted Tooth - Completely Bony | $40 |
| D7241 | Removal of Impacted Tooth-completely bony, with unusual surgical complications | $40 |
| D7250 | Removal of residual tooth roots | $0 |
| D7251 | Coronectomy-intentional partial tooth removal | $0 |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $50 |
| D7280 | Exposure of an unerupted tooth | $85 |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | $85 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | $0 |
| D7286 | Incisional biopsy of oral tissue-soft | $0 |
| D7310 | Alveoloplasty in conjunction with extractions- four or more teeth or tooth spaces, per quadrant | $30 |
| D7311 | Alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant | $30 |
| D7320 | Alveoloplasty not in conjunction with extractions- four or more teeth or tooth spaces, per quadrant | $40 |
| D7321 | Alveoloplasty not in conjunction with extractions- one to three teeth or tooth spaces, per quadrant | $40 |
| D7450 | Removal of benign odontogenic cyst or tumor-lesion diameter up to 1.25 cm | $0 |
| D7451 | Removal of benign odontogenic cyst or tumor-lesion diameter greater than 1.25 cm | $0 |
| D7471 | Removal of lateral exostosis | $0 |
| D7472 | Removal of torus palatinus | $0 |
| D7473 | Removal of torus mandibularis | $0 |
| D7510 | Incision and drainage of abscess-intraoral soft tissue | $0 |
| D7922 | Placement of Intra-socket biological dressing to aid in hemostasis or clot stabilization, per site | $0 |
| D7961 | Buccal/labial frenectomy | $0 |
| D7962 | Lingual frenectomy | $0 |
| D7970 | Excision of hyperplastic tissue-per arch | $50 |
| D7971 | Excision of pericoronal gingiva | $50 |
| Orthodontics | ||
| The benefit for pre-treatment records and diagnostic services includes: | $300 | |
| D0210 | Intraoral-complete series of radiographic image | |
| D0251 | Extraoral posterior dental radiographic image | |
| D0322 | Tomographic survey | |
| D0330 | Panoramic radiographic image | |
| D0340 | 2D cephalometric radiographic image | |
| D0350 | 2D oral/facial photographic images obtained intraorally or extraorally | |
| D0351 | 3D photographic image | |
| D0470 | Diagnostic casts | |
| The benefit for post-treatment records includes: | $120 | |
| D0210 | Intraoral-complete series of radiographic images | |
| D0470 | Diagnostic casts | |
| D8010 | Limited orthodontic treatment- primary | $230 |
| D8020 | Limited orthodontic treatment- transitional | $230 |
| D8030 | Limited orthodontic treatment- adolescent- to age 19 | $230 |
| D8040 | Limited orthodontic treatment- adult | $430 |
| D8050 | Interceptive orthodontic- primary | $230 |
| D8060 | Interceptive orthodontic- transitional | $230 |
| D8070 | Comprehensive orthodontic- transitional up to age 19 | $490 |
| D8080 | Comprehensive orthodontic adolescent up to age 19 | $490 |
| D8090 | Comprehensive orthodontic adult dentition-adult | $490 |
| D8660 | Pre-orthodontic treatment examination to monitor growth and development (enrollee pays a $25 fee if orthodontic treatment is not required or is declined by the Enrollee | $0 |
| D8670 | Periodic Orthodontic Treatment Visit - charge per month for 24 months | $40 |
| D8680 | Orthodontic Retention - Removal of Appliances, Construction and Placement of Retainer(s) | $0 |
| D8681 | Removable orthodontic retainer adjustment | $0 |
| D8999 | Unspecified orthodontic procedure, by report | $200 |
| Miscellaneous Services | ||
| D9110 | Palliative (Emergency) Treatment, Minor Procedure | $5 |
| D9211 | Regional block anesthesia | $0 |
| D9212 | Trigeminal division block anesthesia | $0 |
| D9215 | Local anesthesia in conjunction with operative or surgical procedures | $0 |
| D9219 | Evaluation for moderate sedation, deep sedation or general anesthesia | $0 |
| D9222 | Deep sedation/general anesthesia- first 15 minutes | $83 |
| D9223 | Deep sedation/general anesthesia-each subsequent 15 minute increment | $83 |
| D9239 | Intravenous moderate (conscious) sedation/analgesia-first 15 minutes | $83 |
| D9243 | Intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute increment | $83 |
| D9310 | Consultation, other than Requesting Dentist | $0 |
| D9311 | Consultation with a medical health care professional | $0 |
| D9430 | Office Visit for Observation | $5 |
| D9440 | Office Visit-after regularly scheduled hours | $20 |
| D9450 | Case presentation, detailed and extensive planning | $0 |
| D9932 | Cleaning and inspection of removable complete denture, maxillary | $0 |
| D9933 | Cleaning and inspection of removable complete denture, mandibular | $0 |
| D9934 | Cleaning and inspection of removable partial denture, maxillary | $0 |
| D9935 | Cleaning and inspection of removable partial denture, mandibular | $0 |
| D9943 | Occlusal guard adjustment | $10 |
| D9944 | Occlusal guard-hard appliance, full arch (limited to D9944, D9945, D9946 in 24 months) | $95 |
| D9945 | Occlusal guard-soft appliance, full arch (limited to D9944, D9945, or D9946) in 24 months | $95 |
| D9946 | Occlusal guard-hard appliance, partial arch (limited to D9944, D9945 or D9946) in 24 months | $95 |
| D9951 | Occlusal adjustment, limited | $20 |
| D9952 | Occlusal adjustment, complete | $40 |
| D9975 | External bleaching for home application, per arch; includes materials and fabrication of custom trays, limited to one bleaching tray and gel for two weeks of self-treatment | $125 |
| D9986 | Missed appointment-without 24 hour notice | $10 |
| D9987 | Cancelled appointment-without 24 hour notice | $10 |
| D9990 | Certified translation or sign-language services, per visit | $0 |
| D9991 | Dental case management- care coordination | $0 |
| D9992 | Dental case management-real-time encounter | $0 |
| D9995 | Teledentistry - synchronous; real- time encounter | $0 |
| D9996 | Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review | $0 |
| D9997 | Dental case management-patients with special Health Care Needs | $0 |
| Copyright © 2026 by Segal. All rights reserved. Unauthorized replication or use of this financial workbook is prohibited. | ||
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. This file cannot be copied or reproduced in any method without the written consent by Segal. |
Active DPPO-PGs
| San Bernardino County — Dental RFP |
| Attachment P – Performance Guarantees |
| Active Self-Insured DPPO Plan |
For the following categories, provide the performance standard you are willing to offer, the financial penalty (maximum dollar amount or % of administrative fees) you will agree to pay if the standard is not met.
| Performance Guarantee | Frequency | Percent of Administration | ||
| at Risk | Proposed Guarantees |
(Deviations Only)
| 1. Account Management | |||
| A sales account executive and account manager will be assigned as contacts for the San Bernardino County to: | Measurement will be on a client-specific basis and reported annually. | ||
| a) Successfully oversee all implementation activities. | 1.5% | ||
| b) Return phone calls from San Bernardino County primary contacts within 24 hours. | 1.5% | ||
| 2. Eligibility | |||
| 97% or higher - Electronic eligibility changes are made within 2 business days from receipt of data. Guarantee is contingent upon receipt of data in a mutually agreed upon format and system availability. | Measurement will be on a global basis and reported annually. | 1.0% | |
| 3. Claims Turnaround | |||
| 90% of claims received will be processed within 15 calendar days and 99% of claims received will be processed within 30 calendar days. Claims turnaround is measured from the date of the initial receipt of the claim with complete information to the date the claim is originally processed. | Measurement will be on a global basis and reported annually. | 1.0% | |
| 4. Overall Claims Accuracy | |||
| 96% or higher – Claims are to be processed without error; error does not have to have financial impact. | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 99% or higher – Claims processed will be free from financial error. (Financial Accuracy) | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 5. Customer Service | |||
| 85% of all customer calls to the Contact Center will be answered within 30 seconds or less. | Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | |
| Customer calls to the Customer Service Department will be answered within 30 seconds or less on average. | Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | |
| 5% or less – Call abandonment rate. | |||
| Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | ||
| 6. Contract | |||
| Renewal notification and contractual amendments delivered to the County each year specified in the contract term. | Measurement will be on a client-specific basis and reported annually. | 1.5% | |
| 7. Quality Management | |||
| A written response will be provided that acknowledges receipt of the grievance within five (5) calendar days for 95% of enrollees filing a grievance. | |||
| Measurement will be on a global basis and reported annually. | 1.5% | ||
| 8. Customer Satisfaction | |||
| 85% or higher – Enrollee satisfaction with their network provider. | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 85% or higher – Overall Enrollee satisfaction rate with the vendor. | |||
| Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | ||
| 9. Network Stability | |||
| Network Development would agree to contact 100% of non-participating providers in San Bernardino County a minimum of 2 times during the next year. | Measurement will be on a client-specific basis and reported annually. | 1.5% | |
| 10. Group Report | |||
| Vendor will provide annual County-specific fee/premium/ claims experience reporting and other reports as agree upon (within 30 days of the close of the established reporting period). | |||
| Measurement will be on a client-specific basis and reported annually. | 1.5% | ||
| 11. ID Cards | |||
| 90% or higher - ID cards will be distributed within 10 business days of receipt of eligibility. | Measurement will be on a global basis and reported annually. | 1.0% | |
| Total Administration at Risk | 19% | ||
| Comments: |
| Copyright © 2026 by Segal. All rights reserved. Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. This file cannot be copied or reproduced in any method without the written consent by Segal. |
https://work.segalco.com/work/link/d/WEST!6004946.1https://work.segalco.com/work/link/d/WEST!6005848.1 Active DHMO-PG
| San Bernardino County — Dental RFP |
| Attachment P – Performance Guarantees |
| Active Fully-Insured DHMO Plan |
For the following categories, provide the performance standard you are willing to offer, the financial penalty (maximum dollar amount or % of administrative fees) you will agree to pay if the standard is not met.
| Performance Guarantee | Frequency | Percent of Administration | ||
| at Risk | Proposed Guarantees |
(Deviations Only)
| 1. Account Management | |||
| A sales account executive and account manager will be assigned as contacts for the San Bernardino County to: | Measurement will be on a client-specific basis and reported annually. | ||
| a) Successfully oversee all implementation activities. | 1.5% | ||
| b) Return phone calls from San Bernardino County primary contacts within 24 hours. | 1.5% | ||
| 2. Eligibility | |||
| 97% or higher - Electronic eligibility changes are made within 2 business days from receipt of data. Guarantee is contingent upon receipt of data in a mutually agreed upon format and system availability. | Measurement will be on a global basis and reported annually. | 1.0% | |
| 3. Claims Turnaround | |||
| 90% of specialty claims will be processed within 15 calendar days and 99% of specialty claims will be processed within 30 calendar days. Claims turnaround is measured from the date of the initial receipt of the claim with complete information to the date the claim is originally processed. | Measurement will be on a global basis and reported annually. | 1.0% | |
| 4. Overall Claims Accuracy | |||
| 96% or higher – Specialty claims are to be processed without error; error does not have to have financial impact. | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 99% or higher – Specialty claims processed will be free from financial error. (Financial Accuracy) | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 5. Customer Service Responsiveness | |||
| 85% of all customer calls to the Contact Center will be answered within 30 seconds or less on average. | Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | |
| Customer calls to the Customer Service Department will be answered within 30 seconds or less on average. | Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | |
| 5% or less – Call abandonment rate. | |||
| Measurement over the course of a contract year. Measurement will be on a client-specific basis and reported annually. | 1.0% | ||
| 6. Contract | |||
| Renewal notification and contractual amendments delivered to the County each year specified in the contract term. | Measurement will be on a client-specific basis and reported annually. | 1.5% | |
| 7. Quality Management | |||
| A written response will be provided that acknowledges receipt of the grievance within five (5) calendar days for 95% of enrollees filing a grievance. | |||
| Measurement will be on a global basis and reported annually. | 1.5% | ||
| 8. Customer Satisfaction | |||
| 85% or higher – Enrollee satisfaction with their network provider. | Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | |
| 85% or higher – Overall Enrollee satisfaction rate with the vendor. | |||
| Measurement over the course of a contract year. Measurement will be on a global basis and reported annually | 1.0% | ||
| 9. Network Stability | |||
| Network Development would agree to contact 100% of non-participating providers in San Bernardino County a minimum of 2 times during the next year. | Measurement will be on a client-specific basis and reported annually. | 1.5% | |
| 10. Group Report | |||
| Vendor will provide annual County-specific fee/premium/ claims experience reporting and other reports as agree upon (within 30 days of the close of the established reporting period). | |||
| Measurement will be on a client-specific basis and reported annually. | 1.5% | ||
| 11. ID Cards | |||
| 90% or higher - ID cards will be distributed within 10 business days of receipt of eligibility. | Measurement will be on a global basis and reported annually. | 1.0% | |
| Total Administration at Risk | 19% | ||
| Comments: |
| Copyright © 2026 by Segal. All rights reserved. Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. This file cannot be copied or reproduced in any method without the written consent by Segal. |
Retirees
Ret DPPO-Pricing
| San Bernardino County — Dental RFP |
| Attachment E - Cost |
| Retiree Fully-Insured DPPO Plans |
If bidding, this form must be completed in its entirety. Please do not alter, add or delete rows. Failure to complete this exhibit as requested may results in rejection of your offer.
| 5-Year Rate Guarantee | |
| 5 Year Guarantee | |
| Retiree DPPO | 01/1/2028 - 12/31/2032 |
| Column1 | Column12 |
| Low Option - Monthly Rate - Current Benefits | |
| Single | |
| Two-Party | |
| Family | |
| High Option - Monthly Rate - Current Benefits | |
| Single | |
| Two-Party | |
| Family | |
| High Option - Monthly Rate - Alternative Option 1 | |
| Single | |
| Two-Party | |
| Family |
| 3-Year Initial Rate Guarantee with Option Years | |||
| 3 Year Guarantee | Year 4 | Year 5 | |
| Retiree DPPO | 01/1/2028 - 12/31/2030 | 01/1/2031 - 12/31/2031 | 01/1/2032 - 12/31/2032 |
| Column1 | Column2 | Column3 | Column4 |
| Low Option - Monthly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| High Option - Monthly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| High Option - Monthly Rate - Alternative Option 1 | |||
| Single | |||
| Two-Party | |||
| Family | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| Copyright © 2026 by Segal. All rights reserved. | |||
| Unauthorized replication or use of this financial workbook is prohibited. | |||
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. | |||
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Ret DHMO-Pricing
| San Bernardino County — Dental RFP |
| Attachment E - Cost |
| Retiree Fully-Insured DHMO Plan |
If bidding, this form must be completed in its entirety. Please do not alter, add or delete rows. Failure to complete this exhibit as requested may results in rejection of your offer.
| 5-Year Rate Guarantee | |
| 5 Year Guarantee | |
| Retiree DHMO | 01/1/2028 - 12/31/2032 |
| Column1 | Column12 |
| DHMO - Monthly Rate - Current Benefits | |
| Single | |
| Two-Party | |
| Family |
| 3-Year Initial Rate Guarantee with Option Years | |||
| 3 Year Guarantee | Year 4 | Year 5 | |
| Retiree DHMO | 01/1/2028 - 12/31/2030 | 01/1/2031 - 12/31/2031 | 01/1/2032 - 12/31/2032 |
| Column1 | Column2 | Column3 | Column4 |
| DHMO - Monthly Rate - Current Benefits | |||
| Single | |||
| Two-Party | |||
| Family | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| Rate for Years 4 and 5 | |||
| Rate Guarantee (Y/N) | |||
| Not-to-exceed Rate Cap (Y/N) | |||
| Copyright © 2026 by Segal. All rights reserved. | |||
| Unauthorized replication or use of this financial workbook is prohibited. | |||
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. | |||
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Ret DPPO-Low Benefits
| San Bernardino County — Dental RFP |
| Attachment N – Dental Plan Benefit Design Summary |
| Retiree Fully-Insured DPPO Low Option (All States Except Texas) |
Complete the grid indicating any difference in benefit design offered. Please leave cells BLANK if proposed plan design offered is the same as requested.
| Current | Proposed (Deviations Only) | |||||
| Plan Design | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Networks | PPO Tier 1 (PPO) | PPO Tier 2 (Premier) and Non-Contracted Providers | ||||
| Deductible (Class II, III and IX Expenses) | $50 per person / | |||||
| $150 per family | $50 per person / |
$150 per family
| Annual Maximum (Class II, III and IX Expenses) | $1,000 per person | $1,000 per person | |
| Orthodontia Lifetime Maximum (Class IV) | Not Covered | Not Covered | |
| Orthodontia Adult or Child Coverage | Not Covered | Not Covered | |
| Reimbursement Levels | Based on Reduced Contracted Fees | Based on Reduced Contracted Fees or 80th percentile of UCR allowances | |
| Class I - Preventive & Diagnostic | |||
| Oral Exams | 100% | 70% | |
| Routine Cleanings | 100% | 70% | |
| Full Mouth X-rays | 100% | 70% | |
| Bitewing X-rays | 100% | 70% | |
| Panoramic X-ray | 100% | 70% | |
| Periapical X-rays | 100% | 70% | |
| Fluoride Application | 100% | 70% | |
| Sealants | 100% | 70% | |
| Space Maintainers | 100% | 70% | |
| Emergency Care to Relieve Pain | 100% | 70% | |
| Histopathologic Exams | 100% | 70% | |
| Class II - Basic Restorative | No Waiting Period | No Waiting Period | |
| Fillings | 80% | 60% | |
| Root Canal Therapy/Endodontics | 80% | 60% | |
| Osseous Surgery | 80% | 60% | |
| Periodontal Scaling and Root Planing | 80% | 60% | |
| Denture Adjustments and Repairs | 80% | 60% | |
| Oral Surgery | 80% | 60% | |
| Anesthetics | 80% | 60% | |
| Surgical Extractions of Impacted Teeth | 80% | 60% | |
| Repairs to Crowns and Inlays | 80% | 60% | |
| Class III - Major Restorative | No Waiting Period | No Waiting Period | |
| Crowns | 50% | 50% | |
| Inlays/Onlays | 50% | 50% | |
| Prosthesis Over Implant | 50% | 50% | |
| Dentures | 50% | 50% | |
| Bridges | 50% | 50% | |
| Class IV - Orthodontia | Not Covered | Not Covered | |
| Class VI | |||
| Major & Minor Periodontics | Not Covered | Not Covered | |
| Anesthesia | Not Covered | Not Covered | |
| Sealants | Not Covered | Not Covered | |
| Class IX - Surgical Implants | Not Covered | Not Covered | |
| Enhanced Benefits for Participants with one of the following chronic inflammation-related medical conditions: Diabetes, heart disease, stroke, HIV/AIDS and rheumatoid arthritis | |||
| D4341: One Scaling and Root Planing | 80% | 60% | |
| Four of the following (any combination) per calendar year: | |||
| D1110 or D1120: Prophylaxis (teeth cleaning) | 100% | 70% | |
| D4346: Scaling in presence of moderate or severe gingival inflammation | 100% | 70% | |
| D4910: Periodontal maintenance procedure | 100% | 70% |
Comments:
| Copyright © 2026 by Segal. All rights reserved. |
| Unauthorized replication or use of this financial workbook is prohibited. |
| This Request For Proposal form is the sole property of Segal and is not intended to be reproduced for any purpose other than review by the Plan Sponsor contracted with Segal to prepare a procurement analysis. |
| This file cannot be copied or reproduced in any method without the written consent by Segal. |
Ret DPPO-Low Benefits_TX
| San Bernardino County — Dental RFP |
| Attachment N – Dental Plan Benefit Design Summary |
| Retiree Fully-Insured DPPO Low Option (Texas Only) |
Complete the grid indicating any difference in benefit design offered. Please leave cells BLANK if proposed plan design offered is the same as requested.
| Current | Proposed (Deviations Only) | |||||
| Plan Design | In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Networks | PPO Tier 1 (PPO) | PPO Tier 2 (Premier) and Non-Contracted Providers | ||||
| Deductible (Class II, III and IX Expenses) | $50 per person / | |||||
| $150 per family | $50 per person / |
$150 per family
| Annual Maximum (Class II, III and IX Expenses) | $1,000 per person | $1,000 per person | |
| Orthodontia Lifetime Maximum (Class IV) | Not Covered | Not Covered | |
| Orthodontia Adult or Child Coverage | Not Covered | Not Covered |
This is the start of the file's text. The full file is on GovTribe.
Other files
| File | Type | Posted |
|---|---|---|
| 2026 San Bernardino County - Dental RFP~2.pdf | ||
| San Bernardino County - 2026 Dental RFP Questionnaire (Attachment M)~1.xlsx | XLSX spreadsheet |
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