2020/12/16 Council Agenda Packet

Section 4 Dental Coverage 4.1 Agreement to Provide Covered Services. The Company shall provide benefits for prescribed Covered Services listed as covered in the appendices. Covered Services must be provided by the Participating Provider, except as specified otherwise. All Covered Services are expressly subject to the Copayments, exclusions, limitations, and all other provisions of this Contract. Enrollees may freely contract at any time to obtain health care services outside of this Contract or for services not covered under this Contract on any terms or conditions acceptable to the health care provider and Enrollee. 4.2 Referrals. The Participating Provider may refer Enrollees to a Specialist or Non -Participating Provider for Covered Services. The Company agrees to provide benefits for Covered Services provided by a Specialist or Non -Participating Provider only if: a. The Participating Provider refers the Enrollee; b. The Covered Services are specifically authorized by the Participating Provider's referral and c. The Covered Services are listed as covered in the appendices and are not otherwise limited or excluded. 4.3 Dental Emergency. 4.3.1 Participating Providers will provide treatment for Dental Emergencies during office hours. The Company will provide benefits for Covered Services provided by Participating Providers for treatment of a Dental Emergency. If the Participating Providers' offices are closed, the Enrollee may access after-hours telephonic clinical assistance by calling the Appointment Center at 1.855.4DENTAL (1-855-433-6825) There is no cost for accessing after-hours telephonic clinical assistance. 4.3.2 The Enrollee may seek treatment for a Dental Emergency from a Non -Participating Provider if the Enrollee is more than 50 miles from any Participating Provider office. The Company will reimburse the Enrollee up to the out of area emergency reimbursement amount less any Copayments specified in Appendix A for the cost of the Covered Services. The Enrollee must submit a written request for reimbursement to the Company no later than 6 months after the date of service. The written request should include the Enrollee's signature, the attending Non -Participating Provider's signature, and the attending Non - Participating Provider's itemized statement. Additional information, including X-rays and other data, may be requested by the Company to process the request. The benefit for out of area Dental Emergency treatment will not be provided if the requested information is not received. 4.4 Dual Coverage. A Member may not be covered more than once as a Member under this Contract. 4.5 Coordination of Benefits. This coordination of benefits (COB) provision applies when a person has dental coverage under more than one Plan. Plan is defined below. 001 L-WA811(5/20) 7